by Kul Chandra Gautam
Distinguished Speakers Series in Celebration of 50th Anniversary of USAID
Washington, DC, 6 June 2012
I feel immensely honoured to be asked to address this impressive gathering as part of the Distinguished Speakers Series in Celebration of the 50th Anniversary of the US Agency for International Development (USAID). And I am particularly thrilled to speak about USAID’s historic contribution and leadership role in what came to be known as a global Child Survival and Development Revolution (CSDR), of which we are celebrating the 30th anniversary this year.
I have many vivid personal memories of how UNICEF, the agency I worked for over three decades, and USAID collaborated closely in initially conceptualizing and then implementing on a massive scale that ambitious programme starting in 1982.
The revolution for child survival and development continues to this day producing impressive results. Many old skeptics have become converts over time, and many new actors have joined the revolution. To its credit, USAID has remained the most steadfast and unwavering champion of child survival despite many changes in the US government administrations, the US Congress, and the many organizational and even philosophical changes over the decades in USAID itself.
I am delighted that under the leadership of Dr. Rajiv Shah, and with the full backing of Secretary of State Hillary Clinton and President Obama, child survival continues to command USAID’s continuing priority. A testimony of that continuing commitment is the high level forum on Child Survival Call to Action with the theme of “A Promise to Keep: Ending Preventable Child Deaths” that the US government will co-host with the governments of India and Ethiopia, along with UNICEF and other partners next week here in Washington DC.
This is a fitting moment for such a high level forum as the international community is now engaged in a last push to achieve the Millennium Development Goals and to plan for a new sustainable development agenda beyond MDGs.
This afternoon, I have been asked to share with you my recollection of the origins of this great revolution, some of its major milestones, and lessons learned for the future.
President Kennedy’s Vision for CSDR and USAID
The philosophical underpinnings of the CSDR can be traced back to the establishment of the US Agency for International Development (USAID) by President John F Kennedy in 1961.
Senator William Fulbright of Arkansas, one of the most enlightened Congressional leaders in shaping US foreign policy in the 20th century, helped President Kennedy to shepherd through the 1961 Foreign Assistance Act, which enabled the President to establish USAID through an executive order.
USAID was created through the merger of several earlier aid mechanisms including the Economic Cooperation Administration which had spearheaded the famous Marshall Plan after World War II; and the International Cooperation Administration (ICA), the immediate predecessor of USAID.
President Kennedy was frank and firm in articulating his vision for a muscular agency to stand behind U.S. efforts to promote global peace and prosperity through long-term assistance for economic and social development. He outlined the moral purpose behind US aid and international cooperation when he said in his inaugural address: “To those peoples in the huts and villages of half the globe, struggling to break the bonds of mass misery, we pledge our best efforts to help them help themselves…If a free society cannot help the many who are poor, it can never serve the few who are rich.”
Jim Grant’s Inspiration
Among the many Americans who were inspired by Kennedy’s words and sentiments, there was a young official named James P Grant who at that time was working at the Washington Headquarters of the International Cooperation Administration before it became USAID. Grant briefly worked at the Kennedy White House as a member of the National Security Council before returning to USAID and heading off to Turkey as USAID’s country Director. Earlier during the ICA days he had served as its country director in Sri Lanka, then called Ceylon.
In Sri Lanka, Grant had been impressed with and encouraged the country’s success in promoting basic health and education even when it was economically very poor. In Turkey he had witnessed and encouraged the success of the ‘Green Revolution’ which had helped increase food production dramatically using some new technologies, and high yielding crop strains.
His experience in Sri Lanka and Turkey, and earlier in China where he had witnessed his medical missionary father, John Grant, spearhead the ‘barefoot doctor’ movement, had convinced Jim Grant that dramatic changes could be made in people’s well-being if proven, innovative technologies were applied on a large scale. Besides technology, he had noted that other ingredients of success were – political commitment, access to essential commodities, credit and financing, and training and social mobilization on a massive scale.
When Grant returned to USAID HQ in the late 60s as an Assistant Administrator, he continued to mull over how to implement President Kennedy’s vision and how to cut short the conventional incremental development approach that focused excessively on economic, infrastructure and industrial growth as the key engines of development. He was increasingly convinced that it was actually investment in human development, especially building a strong foundation of healthy and educated human resources that would unlock the levers of development more effectively and faster than any other approach.
To give himself more space and independence to pursue this line of research and to influence the US and other international aid policies through advocacy, he quit a budding career at USAID and founded a small, independent think-tank called the Overseas Development Council (ODC). As President of ODC, Grant produced periodic reports with analyses and recommendations for how to make US foreign aid more effective. ODC’s reports were widely read, including by Congressional leaders who were involved in appropriating budget allocation for foreign aid.
Inadequacies of GNP
During his time at ODC, Grant developed and started championing a school of thought which later became known as human development. Development, he argued, had to be measured not solely or mainly by the gross national product (GNP) of a nation but by the physical quality of life of its citizens.
Infant mortality, life expectancy, literacy and other social indicators were far more sensitive and important measurements of a nation’s development than a country’s GNP, he argued.
This line of thinking, that the much vaunted GNP was not necessarily the best measure of development was beautifully reflected in a memorable address by Robert Kennedy at the University of Kansas in March 1968 just a few weeks before his assassination, when he said:
“…the gross national product does not allow for the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages; the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage; neither our wisdom nor our learning; neither our compassion nor our devotion to our country; it measures everything, in short, except that which makes life worthwhile. And it tells us everything about America except why we are proud that we are Americans.”
The years of the Kennedy and Johnson administrations were known as the first UN “decade of development” and were a time of tremendous growth in international development assistance. Grant’s ODC indirectly played a role in influencing both the increase in development assistance and in setting quantifiable development goals and targets, always trying to ensure that indicators such as reduction of infant mortality, fertility, illiteracy and life expectancy figured prominently.
In 1976 Grant even got an influential global think tank, the Club of Rome to issue a report entitled “Reshaping the International Order” which called for setting of global targets in infant mortality, life expectancy, literacy and lowered birth rate to be reached by the end of the century.
Grant was both a great believer and a passionate champion of such targets and goals both as proxy measurements of reduction in poverty and underdevelopment, and as a way of popularizing these issues to create political will behind social and economic programmes.
Grant’s Vision of Child Survival and Development Revolution
In 1980, Jim Grant was appointed as head of UNICEF by Secretary-General of the United Nations, Javier Perez de Cuellar on the recommendation of President Jimmy Carter. Prior to his appointment, Grant had been the US representative to the UNICEF Executive Board.
He came to UNICEF bubbling with grand ideas, and bouncing with extraordinary energy and enthusiasm. It was as if all his life he had been preparing to come to lead UNICEF, which provided him the perfect bully pulpit to espouse his ideas and vision.
Grant assembled a team of high caliber thinkers, doers and managers from around the world to advise and assist him. Beyond UNICEF staff, he reached out to the media and academia, and the development think tanks of the world.
In 1982, he articulated a bold vision of unleashing a Child Survival Revolution. It was unconscionable, he argued, that 40,000 children a day, or 15 million annually, were dying at that time, when there were many low-cost, readily available interventions to prevent such deaths.
Like the Green Revolution that multiplied agricultural production and prevented famine in Asia, he argued that a child survival revolution could drastically cut down child deaths and unleash a virtuous cycle of child well-being and human development.
Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization, were proposed as the cutting edge interventions, supported by female education, family planning, and food supplements – known as GOBI-FFF. Of these, immunization and ORT were seen as the most promising ‘twin-engines’ of the child survival revolution.
Grant promoted CSDR with an infectious passion. He visited over a hundred countries and met their leaders – some of them multiple times. He initiated the publication of an annual State of the World’s Children report which ranked countries according to their child mortality rate. Arguing that morality must march in tandem with capacity, he persuaded leaders of the world to raise immunization rates from single digits to 80 percent in less than a decade, by 1990.
To demystify the low-cost, high impact child survival and development interventions and to make these readily accessible to every family, UNICEF published a simple do-it-yourself manual entitled: “Facts for Life”. Nearly 20 million copies of that book are in use worldwide, in 215 languages. Only the Holy Bible is known to have been translated in more languages than “Facts for Life”!
To reach children in situations of conflict, UNICEF promoted temporary cease-fires using the concepts of “Days of tranquility”, “corridors of peace” and “bubbles of child protection” in conflict zones ranging from El Salvador to Sudan, Iraq to Sri Lanka, and elsewhere.
Going beyond child survival, Jim Grant gave the decisive push to the long languishing negotiations on the UN Convention on the Rights of the Child, and saw it come to completion and into effect in 1989. He then pushed hard for its ratification, making it the world’s most universally embraced human rights treaty (alas, with the singular significant exception of the United States of America).
Grant’s crowning achievement was the convening of the World Summit for Children in 1990. It was the first ever world Summit, attended by the largest gathering of world leaders in history until that time.
I personally had the great privilege to work closely with Jim Grant, including serving as his point man to draft the “World Declaration and Plan of Action for the Survival, Development and Protection of Children” which was endorsed by the Children’s Summit. The Summit laid down many time-bound and measurable development goals committing world leaders to accord a “First Call for Children” in allocating resources in good times as well as bad.
Early Results of Child Survival Revolution
What was the net result of all this effort?
Compared to early 1980s, some 10,000 fewer children died every day a decade later, thanks to the increase in childhood immunization from less than 20 percent to nearly 80 percent, and similar rise in oral rehydration therapy and other child survival interventions.
Cumulatively, it was estimated that the lives of some 25 million children were saved during Jim Grant’s tenure as UNICEF Executive Director, leading the New York Times columnist Nicholas Kristof to say that, “…the late James P. Grant, a little-known American aid worker who headed UNICEF from 1980 to 1995 and launched the child survival revolution with vaccinations and diarrhea treatments, probably saved more lives than were destroyed by Hitler, Mao and Stalin combined”.
Besides saving lives, CSDR led to improved health and nutrition, and enhanced learning and earning capacity of millions of children through such measures as: prolonged breastfeeding; significant reduction in vitamin A, iodine and iron deficiencies; improved hygiene and sanitation; basic education and women’s empowerment.
Most importantly, advocacy of CSDR led to elevating the well-being of children high on the world’s development and political agenda as a subject of regular discussion in Summit meetings of world leaders, and a topic of increased media coverage.
Many of today’s UN Millennium Development Goals (MDGs), were inspired by the goals of the World Summit for Children, and hence focus heavily on the survival and development of children.
Vindication of the ‘Mad American’
But at the beginning, some of Jim Grant’s ideas were considered very heretical, outlandish, idealistic and even naïve. Some Europeans even accused him of being a ‘Mad American’ with a missionary zeal and over-blown ambition. Initially, it was not easy to convince even the World Health Organization that these child-specific goals would not detract from its pursuit of a more holistic primary health care approach approved at the historic Alma Ata Conference.
Some even accused Grant and UNICEF of pursuing a vertical, mono-focal campaign approach that would be unsustainable. These fears and accusations were unfounded as Grant’s vision for development was indeed quite broad and holistic as many of his close colleagues knew all along, and many detractors realized later. But the early years of CSDR were as challenging as they were exhilarating.
Some critics argued that Jim Grant over-simplified the world’s development challenges by boiling them down to just a few technical interventions aimed at reducing child mortality. After all, development is much more than reducing the quantity of deaths. How about the quality of life, social justice, gender equality, economic development, human rights, protection of the environment, and building of systems and infrastructure to sustain development gains?
For those who knew Jim Grant, this was a false and superficial critique. Far from being simplistic and narrowly focused, Grant had a broad and holistic vision of development. He was very aware of the multi-faceted nature and complexities of development. He spoke forcefully on issues ranging from the need to end the “apartheid of gender”, to reducing military expenditures, providing debt relief and fair terms of trade for developing countries.
He argued for restructuring foreign aid and national development budgets in favour of basic social services. He challenged the prevailing orthodoxy of powerful international financial institutions and called for “adjustment with a human face”.
Let us recall that in the 1980s, the structural adjustment policies imposed by the World Bank and IMF forced many governments to balance their budget by cutting expenditures on health, education and social services. The consequences were immediate and devastating – rates of malnutrition increased, governments were unable to replenish essential drugs or even pay the salaries of health workers and teachers. It was the poor people, and especially children, who suffered most from such cut-backs.
Grant protested loudly, and got UNICEF to make a well-reasoned and passionate case for protecting the poor and vulnerable in designing structural adjustment programmes. UNICEF’s call for “adjustment with a human face” gathered strong support from development activists, and eventually forced the World Bank and IMF to change their policies.
Child Survival as ‘Trojan Horse’ for Human Development
Grant advocated for the child survival revolution with a small number of highly “doable” interventions, not as a simplistic formula for just reducing mortality, but as a “Trojan Horse” for combating poverty, promoting democracy, slowing down population growth and accelerating economic development.
Nothing is more disempowering to parents than to see their children die. Inability to save their children makes parents feel powerless and fatalistic. On the other hand, when parents feel that they can take action to save their children’s lives, they feel a sense of empowerment rather than helplessness.
When parents know that simple, low-cost actions can save their children, they begin to demand such services. When parents feel confident that their first children will survive, they tend to have fewer children. When they have fewer children, they care more about giving them the best possible education and upbringing.
Thus starts a virtuous cycle of empowerment and upward mobility.
Jim Grant’s vision for child survival did not just rely on a few technological fixes to reduce mortality. It called for unleashing the power of social mobilization and moral persuasion with extraordinary transformative power.
Grant personally persuaded hundreds of leaders – democrats and dictators alike – as to why it was in their political interest to promote child survival interventions. He did not want them to be satisfied with small scale pilot projects and marginal, incremental progress. He wanted to see action that was commensurate with the scale of the problems.
Going to scale, shifting gears, making quantum leaps in child survival and development were his sacred mantras.
Ministries of health in most developing countries usually do not have the manpower, financial resources, organizational outreach or political clout to make a quantum jump in immunization and other life-saving services. Recognizing this, Grant developed a two-pronged strategy to overcome this constraint.
On the one hand, he would approach, not just ministers of health but also the presidents, prime ministers, governors and mayors to adopt immunization (and other child survival interventions) as their own programmes and not those of the ministry of health.
Leaders were persuaded that provision of such life-saving services would give them great political dividends and electoral votes at minimal financial cost.
On the other hand, Grant approached religious leaders, the mass media, film stars and sports personalities, and non-governmental organizations to promote immunization, ORT and other child survival actions. In an era before the advent of mobile phones, internet and today’s social media, such outreach and social mobilization greatly reinforced and energized the usually weak and lethargic health ministries.
Finally, the actions or inaction of health services came under national spotlight. This helped to revitalize health services by giving them unprecedented political visibility and subjecting their performance to public accountability.
US Support for Child Survival
To cope with some of the early vehement criticism and skepticism against Grant’s grandiose proposals for a child survival revolution, coming especially from some European members of the UNICEF Executive Board, it was very important that at the very least Grant’s ideas had the solid backing and support of the US government.
To secure US support UNICEF followed four main approaches.
First, UNICEF activated a very energetic citizen’s group then called the US Committee for UNICEF – now the US Fund for UNICEF – which had extensive network of volunteers all over America. It organized “Trick or Treat for Children” during Halloween; greeting card sales during Christmas, public education on the work of UNICEF; and fund-raising for UNICEF. The Committee had extensive outreach in local communities throughout America, partly popularized by such well-known Goodwill Ambassadors as Danny Kaye, Peter Ustinov, Harry Belafonte, later joined by Audrey Hepburn and many others. The Committee managed to secure strong public support for the child survival agenda, including bi-partisan support for UNICEF in the US Congress.
Capitalizing on this impressive outreach, Jim Grant often testified before the US Congress and cultivated influential US media to secure strong American public and government backing for the child survival and development agenda.
A second important group that emerged was a small but increasingly influential NGO called RESULTS. Led by a young and skillful activist named Samuel Daley Harris, RESULTS prepared and placed in dozens of local newspapers all across America very clear and convincing write-ups justifying why a child survival revolution was needed, and how it was feasible and affordable, and urging the US to take a global leadership role.
With the help of hundreds of volunteers and activists in local communities, RESULTS was able to convince editors of newspapers in small towns and cities all across America to publish editorials and op-ed pieces on the imperative of a global child survival movement. Suddenly hundreds of such articles appeared in local newspapers, and the subject of child survival became a topic of discussion in local town-hall meetings. Senators and Congressmen could not ignore this groundswell of grassroots interest and support for a global movement for child survival in their own constituencies.
Thus when Jim Grant and other high profile advocates went before Congress to testify in support of child survival, Senators and Congressmen already had press clippings in front of them from their home-town newspapers sent by their constituents that motivated them to be supportive.
Third, Jim Grant master-minded the establishment of a Task Force for Child Survival in 1984 that brought together representatives of the World Health Organization, the United Nations Development Program, the World Bank, UNICEF and the Rockefeller Foundation. Dr. William Foege, a very distinguished public health leader who had been involved with the smallpox eradication programme and had served as Director of the US Centers for Disease Control served as the Executive Director of the Task Force.
By providing a highly credible, neutral meeting ground, the Task Force was able to help participating organizations to rise above their narrower institutional preoccupations to achieve a common strategic goal. Bill Foege was an internationally respected and articulate leader who became an additional powerful voice reinforcing Jim Grant’s message which convinced the US government and the Congress to lend its full support for the child survival initiatives.
USAID’s Leading Role in Child Survival
Finally, and most importantly, USAID was fully behind the child survival initiative. Peter McPherson, AID’s very able Administrator in the 1980s, became a strong and forceful champion of child survival. In fact, UNICEF and USAID worked out a division of labour whereby UNICEF took the lead role on immunization, and USAID led a global effort to popularize oral rehydration therapy (ORT).
Diarrheal dehydration was the number one cause of child deaths in the world at that time killing nearly 5 of the 15 million children who died annually, and ORT was a proven, low-cost and low-tech solution costing just nickels and dimes to save a child’s life.
But one of the problems with the promotion of the commercial variety of ORS was precisely that the product was so cheap that pharmacists did not make much of a profit on its sale. Unless mothers insisted on buying it because they were convinced that it was really what their ailing child needed, an ignorant —or unscrupulous—drug merchant would rather sell her a coloured capsule which looked more exotic, and was much more expensive, but was almost guaranteed to be an inferior treatment for diarrheal dehydration.
To counter such misunderstanding and to popularize ORT, USAID organized several international conferences on oral rehydration therapy (ICORT). Peter McPherson personally led the effort to organize these ICORTs and to disseminate ORT, putting enough resources and policy priority behind it.
At the first ICORT conference in 1983 McPherson called for the doubling of ORT coverage each year for the next 5 years world-wide, and attaining near universal availability of ORT within a decade as a practical goal, and promised USAID’s support. True to his word, USAID’s funding support tripled in three years since ICORT-I and covered 50 countries.
At ICORT-II in 1985, McPherson promised additional measures – e.g. support for research, incorporating ORT in all USAID supported primary health care projects, asking all USAID country directors to find opportunities to promote and disseminate ORT, introducing Primary Health Care Technology projects (PRITECH) worldwide; and enlisting US Peace Corps Volunteers to promote ORT at community levels.
USAID actively promoted social marketing of ORT using radio, TV, AV, etc. As UNICEF Representative in Haiti in the early 1980s, I personally collaborated with USAID in an ambitious national programme to promote a local brand of ORS called serum oral starting in mid-1983. From virtually no knowledge at all, by mid-1985, eighty per cent of mothers in Port au Prince and thirty per cent of those in the countryside had heard of serum oral and begun to use it with very encouraging results.
Egypt was another flagship example of USAID’s support for ORT. Lectures and workshops were arranged in teaching hospitals, medical colleges and nursing schools, and pharmacists all over the country were encouraged to stock ORS sachets. Within 3 years of Egypt’s ORT community outreach programme, 90 percent of mothers knew about the effectiveness of ORT, and many used it and helped save tens of thousands of child lives every year.
USAID, UNICEF and WHO jointly published a newsletter called Diarrhoea Dialogue – certainly not a very tasteful title for a dialogue – but it reached a readership of 100,000 and became one of the most widely circulated development/health publications in the world.
Today, thanks to USAID’s pioneering leadership and support, a billion episodes of childhood diarrhea are treated with ORT saving the lives of over three million children around the world every year. With the recent discovery of how zinc supplements combined with ORS can have dramatically greater impact in reducing child mortality, morbidity and malnutrition, and the introduction of the new rotavirus vaccine, we are poised for even greater success in promoting child survival in coming years.
Indeed, USAID’s role in support of child survival through ORT dated back to the days when it was discovered in Bangladesh in the late 1960s. USAID had largely financed the brilliant multi-year research that led to the discovery of ORT, which the British medical journal Lancet heralded as “the most important medical advance of this century”. USAID’s pioneering role in the discovery and dissemination of ORT first at the Cholera Research Lab in Bangladesh that later became the International Centre for Diarrhoeal Disease Research in Bangladesh (ICDDR-B), was publicly recognized by a special award from the Prime Minister of Bangladesh in 1994.
UNICEF too presented a special award to USAID for its contribution to Oral Dehydration Therapy, at a ceremony at the US Capitol Hill in March 1994. Presenting the Award to Administrator Brian Atwood, Jim Grant praised how it had taken vision and courage for USAID to embrace ORT the way it did, often in the face of incredulity from elsewhere in the bureaucracy and skepticism from taxpayers unaware of the terrible toll of diarrhoea around the world.
USAID’s support for ORT – and the entire Child Survival and Development Revolution – was truly exemplary. Jim Grant once said that many of the kudos that were showered on UNICEF and others over the years rightfully belonged to USAID and its dedicated leaders and staff.
The collaboration between USAID and UNICEF on child survival produced great results and became very popular. Indeed, even when the US government threatened and actually cut US funding for the UN and its various agencies, there was consistent bi-partisan support for UNICEF and its child survival mission. During the Reagan and Bush-Sr administrations, the White House often proposed reductions in US contribution to the UN, including UNICEF, in the larger context of across the board budget cuts and deficit reduction. But the US Congress consistently restored such cuts and even increased allocations – always with bipartisan support.
Besides the intrinsic merits of promoting child survival, the solid US backing encouraged WHO, the World Bank, European and other donors to join ranks, leading to a true global movement for child survival and development.
Sharing Credit for Child Survival
A special characteristic of Jim Grant was his thoughtfulness and generosity in giving credit to others. In UNICEF’s State of the World’s Children report, and in his public speeches, he unfailingly gave credit to WHO and it’s Director-General for the achievements being made in maternal and child health, even when some UNICEF staff occasionally protested that such recognition was not always warranted or reciprocated.
Grant often reminded us to “never underestimate the amount of good a person can do, if they do not mind who gets the credit”. He was a living embodiment of that principle. He was not only generous in giving credit to others; he also took an enlightened and far-sighted approach in sharing resources with others.
Grant was masterful in mobilizing resources. But he wanted those resources to benefit not just UNICEF but whoever else could help promote the cause of children, and expand the constituency for the cause.
I recall a specific case involving UNICEF, USAID and the US Congress.
As a result of Grant’s persuasive testimony, supported by Bill Foege, Pete McPherson and others, the US Congress established a Child Survival Fund in 1985 with an initial allocation of $25 million. The Congress intended to allocate the full $25 million to UNICEF to accelerate child survival. To the consternation of his staff, and even the Congress, Grant suggested that instead of giving all the funds to UNICEF, it should be shared with USAID, and that USAID should be asked to establish and administer the child survival fund.
His logic was that if a budget line was established for child survival in USAID, it would have a vested interest to maintain that account and would seek increased allocation in future.
Indeed, Grant’s insight was prophetic. Since the child survival fund was established, USAID lobbied the Congress and got regular increases in its allocation from the initial $25 million to $40 million to $80 million, and eventually to over $300 million per year.
Had Grant not been so far-sighted and simply accepted the money for UNICEF, it would most likely have been a one-time allocation of $25 million to UNICEF. Instead he turned it into an opportunity to leverage a multi-year commitment adding up to several billion dollars investment for children through USAID.
Newer Strategies for Accelerating Child Survival
While we celebrate the great achievements in child survival, reducing child deaths from over 50,000 deaths every day at the time of the founding of USAID in 1961 to 21,000 daily deaths five decades later, the continuing loss of 21,000 children every day – or 15 children dying every minute – is a blemish on our human civilization in this day and age.
This death toll is unacceptable because, most of these deaths are readily preventable. It is therefore most fitting that USAID has recently launched a campaign called “Every child deserves a 5th birthday”.
An international momentum is building up for such a campaign. The UN Secretary-General’s Global Strategy for Every Woman Every Child launched in 2010 which seeks to accelerate progress towards MDG 4 and 5 by 2015 is one powerful element of such campaign.
The high level international forum on ‘Child Survival – Call to Action’ being held in Washington, DC on 14-15 June 2012, is another far-sighted and ambitious agenda to end preventable child deaths.
Benefitting from the experience of the past, the child survival strategy in the coming decades will need to deploy some new approaches that the world community has devised in recent years.
Increased childhood immunization must remain a priority. During a period of little blip when there was a perception – though fortunately it was not the reality – that UNICEF had dropped the ball on immunization, the Bill and Melinda Gates Foundation came to the rescue, and mobilized a number of old and new partners and set up the Global Alliance for Vaccines and Immunization (GAVI). GAVI has since become a key player in boosting child survival through increased support for expanded coverage of existing, under-used vaccines, and most importantly, introduction of many new vaccines at drastically reduced cost thanks to GAVI-supported innovative financing mechanisms.
Recognizing the vital role of nutrition and food security, we now have a ‘Scaling Up Nutrition’ –or the SUN movement – that brings together a coalition of partners from governments, NGOs, the private sector, academia and UN agencies. SUN addresses one of the greatest human inequities and social injustices of our time, the chronic deficiency in nutrition, which leaves some 180 million children stunted.
SUN emphasizes that the critical window of opportunity to prevent childhood malnutrition is during the first 1000 days of a child’s life – from conception, through pregnancy, to the age of two. Some focused interventions during these Golden 1000 Days, can protect children from irreversible damage from malnutrition, and enhance their chances of survival and growth. Among the key interventions, combating micronutrient deficiencies must command a high priority as these are among the “best buys” in terms of development results as confirmed by a group of the world’s leading economists, including many Nobel Prize winners, in their ‘Copenhagen Consensus’ report in 2008.
When the child survival revolution was launched in the early 1980s, HIV/AIDS was not yet a major public health issue globally. Since then, it has ravaged societies like a plague, and as usual women and children have been its principal victims. After many trials and errors, the world has now come up with an effective strategy for virtually eliminating the parent to child transmission of HIV/AIDS. The “Countdown to Zero,” global plan to end pediatric AIDS now has a strong global consensus and public support. It needs to be made a key element of the ‘ending preventable child deaths’ campaign.
The great progress in malaria control, especially the private sector and civil society’s activism in providing insecticide treated bed nets and artemesinin based combination therapies (ACTs) has been truly inspiring, and will need to be a corner-stone of child survival, particularly in sub-Saharan Africa.
There are now well-developed plans and strategies for accelerating progress towards universal coverage of clean drinking water, safe sanitation and hygiene. These too must be made part of a broader child survival and development strategy of the future.
The survival and well-being of children are, of course, intricately linked to the good health and well-being of mothers, which is most effectively addressed following the “continuum of care” approach that ensures the survival and health of newborns, access to health care for young children, and their mothers – before, during and after pregnancy.
We now know much about effective interventions that help prevent child deaths and drastically reduce maternal mortality and morbidity. USAID has been a leader in supporting maternal and newborn health care programmes, including through its long-standing support for Save the Children, and more recently through an inter-agency Partnership for Maternal, Newborn and Child Health (PMNCH).
Finally, family planning, food supplements and female education, the FFF components of the original child survival package of GOBI-FFF, remain still as valid today as they were in the 1980s, and must be made part of the renewed child survival and development campaign in the broader context of the post-MDG sustainable development agenda.
Behaviour Change Interventions
Even as we push for increased coverage of life-saving technologies, commodities and medical services, let us recall that most of the world’s major health problems and premature deaths are preventable through changes in human behaviour and at relatively low-cost.
When Dr. Bill Foege was Director of CDC, he often made the interesting point that it would cost more than $10 billion annually to add a single year to the life expectancy of an average American male through medical interventions. But one could add 11 years to their life expectancy through 4 virtually cost-free actions: a) stop smoking, b) moderate alcohol consumption, c) change certain dietary habits, and d) do moderate amount of exercise regularly.
To these one could add a few more behavioural changes, especially relevant in the context of child survival in developing countries today, such as: practice exclusive breastfeeding, hand-washing, safe sex, and prevention of readily avoidable accidents and injuries, etc.
None of these require sophisticated medical technology, highly trained manpower or huge investments. With today’s information and communication technologies, now penetrating even the poor, remote communities, we can do so much more to revolutionize maternal and child health.
Focus on Equity
People often ask me what would Jim Grant’s vision and priorities be today if he were still alive and leading a renewed push to complete the unfinished agenda of the child survival and development revolution. This question was actually addressed by Peter Adamson, a close collaborator of Jim Grant who was editor of the State of the World’s Children reports throughout Grant’s tenure at UNICEF.
Speaking at Grant’s memorial service in February 1995, Adamson opined that while securing large-scale coverage of basic services for children had been Grant’s priority in the second half of the 20th century, his priority for the 21st century would be to focus on equity – to ensure that no child was left behind, that in further expanding basic services, deliberate effort would be made to reach the most deprived and marginalized children.
Interestingly, the current Executive Director of UNICEF, Tony Lake, has made equity and reaching the “bottom quintile” of children his highest priority, thus picking up where Jim Grant had left off.
As we enter the fourth decade of CSDR, we are thus witnessing a rekindling of the spirit of Jim Grant in UNICEF, with renewed focus on the unfinished business of the original child survival revolution, adapted, of course, to new developments and new realities of the 21st century.
The focus on equity and reaching the “bottom quintile” is very timely and appropriate because the great progress we have made in child survival in recent decades, while encouraging, has been very uneven. Children from the bottom quintile in developing countries are two or three times more likely to die before reaching the age of five than those from the richest quintile. The same applies to children who are malnourished or children who are out of school, or women who die during child birth.
As we measure progress towards meeting the MDGs, we are witnessing an alarming widening of disparities between rich and poor countries and within nations. The post-MDG sustainable development agenda must, therefore, make progress with equity its central theme. And the starting point for such an ambitious agenda can and must be a renewed child survival and development campaign.
Indeed, the Child Survival – Call to Action proposes an ambitious global goal of reducing child mortality to below 20 child deaths per 1000 live births in every country, and 15 child deaths per 1000 births worldwide by 2035. Achieving these targets will mean saving an additional 5.6 million lives every year, and bringing the world to a new low of 2 million child deaths per year. Progress of such magnitude is only possible through massive increase in service coverage with deliberate focus on equity and empowerment.
We count on USAID, along with other partners like UNICEF, to play a leading role in such a renewed child survival and development campaign. This would be a fitting tribute to President John F. Kennedy’s vision when he established USAID 50 years ago with the noble ideal of promoting global peace and prosperity through long-term assistance for economic and social development.
As the world’s richest and most powerful nation, the United States of America has an obligation and an opportunity, as President Kennedy said so eloquently, to help “those peoples in the huts and villages of half the globe, struggling to break the bonds of mass misery…to help themselves.” As it celebrates its 50th anniversary, USAID can have no nobler mission than to rededicate itself to this original call to action by its founding father – President Kennedy.