Reflections on Child Survival Revolution

By Kul Chandra Gautam
Hosted by Dartmouth for UNICEF Campus Initiative
Dartmouth College
Hanover, NH, 21 September 2011

I am so delighted to learn that Dartmouth has joined a growing list of universities in America that participate in the UNICEF Campus Initiative. Among the many exciting extra-curricular activities that Dartmouth hosts, I hope that the UNICEF Campus Initiative will gain a place of pride soon.
For there can be no nobler cause than helping the world’s most vulnerable citizens – our children – to survive and thrive.
You have asked me to share some reflections on the Child Survival Revolution that UNICEF has been spearheading for several decades now. As I do so, let me start with a provocative question: why should child survival – or reducing child deaths – be such a high priority when there are so many other pressing problems in the world – from rapid population growth to climate change; from eradicating poverty to combating HIV/AIDS; from preventing wars to promoting human rights?
Why should child survival be a priority?
Well, without being exhaustive, let me share with you a couple of reasons.
First, protecting our young and vulnerable citizens is the very essence of human life and human civilization.
Instead of thinking about the billions of people in the world and millions who die, let us think about our own families. How much importance would each one of us give to saving the lives of our own children, if they were at risk of dying?
I bet that most of us would give it the highest priority.
If saving the lives, protecting the health and maximizing the wellbeing of our own children is so important for each of us, shouldn’t child survival and wellbeing in the world be our collective priority as well?
And look at it from the point of view of the child: if you don’t survive, nothing else counts.
Of course, mere survival is not enough. We also want our children to survive and thrive. We want them to be healthy, well-educated and productive. We want them to grow up to their full human potential.
But a dead child cannot grow up to his or her full potential. Survival is the first step to fulfilling human potential.
Besides being the morally and emotionally the right thing to do, promoting better child survival also helps address many other problems that we worry about.
I will not dwell on the economic arguments for investing in child survival, which are plenty.
But let us take an issue like global warming and climate change – the hottest topic of our times. Why do we care about climate change? Isn’t it because we are worried about the world our children will inherit?
Or put it another way, if you were a parent who cannot even ensure the survival of your own children, would you / should you be expected to care about protecting the earth and its environment?
We care about the earth, the climate change, saving the forests and the endangered species, and about human rights and human wrongs, precisely because we care about our children – and their future.
How about population growth? Sometimes people say that the world is already over-populated, and the focus on child survival will make that problem worse.
Well, on the contrary, experience shows that people begin to have smaller families, and fewer children, only when they are confident that their first children will survive. Thus paradoxically, improving the chances of child survival actually leads to slower population growth rather than to population explosion.
Child survival and well-being are indeed the central concerns around which much of the whole human civilization revolves.
That is why child survival and development are such a central part of the Millennium Development Goals which today comprise the most universally accepted human development agenda promoted by the United Nations.
Now, how are we doing on child survival globally?
The short answer is: better than ever before.
But the longer answer is: not good enough; and certainly not commensurate with our capacity in this 21st century.
UNICEF started keeping score of how many children died globally every year in the 1960s. At that time 20 million children died every year or nearly 55,000 every day.
Just last week, a UN inter-agency group for child mortality estimation led by the World Health Organization and UNICEF came out with a very encouraging report on “Levels and Trends in Child Mortality” which shows that in 2010, the total number of deaths among children under five fell to 7.6 million per year or about 21,000 daily.
While we celebrate this great achievement, 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 in fact readily preventable or easily treatable.
There are many and complex underlying causes of child mortality, but there also are many very simple and low-cost interventions to dramatically reduce child deaths. Simple diarrhoea, pneumonia, malaria and measles continue to be the major killers of children, accounting for half of the world’s child deaths. Infections, malnutrition, neonatal conditions, accidents and injuries, and in some parts of the world, HIV/AIDS, occurring singly or in some combination, account for the rest of child deaths.
Most of these deaths can now be prevented for pennies or at most nickels and dimes a day.
The survival and well-being of children are, of course, intricately linked to the good health and well-being of mothers, and both depend on the “continuum of care” 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 not only prevent child deaths but also reduce maternal mortality and morbidity.
High priority interventions that need to be implemented at scale include:


  • Newborn care, as part of the continuum of care following a life cycle approach;
  • Infant and young child feeding, including micronutrient supplementation and de-worming;
  • Provision of maternal and childhood immunization and accelerated introduction of new vaccines, in particular against pneumonia and rotavirus;
  • Prevention of mother-to-child transmission (PMTCT) of HIV;
  • Prevention of malaria using insecticide-treated bed-nets (ITNs) and intermittent preventive treatment of malaria (IPT);
  • Management of common childhood illnesses applying the Integrated Management of Childhood Illness (IMCI) strategy;
  • Providing reproductive health care and meeting the unmet need of family planning.


All of these interventions are proven and affordable, and none are going to bankrupt any country’s treasury. With modest technical, policy and financial support from donors, even the poorest countries in the world can launch such programmes.

Indeed, many already have, with good results.

In recent decades, progress in reducing child mortality in Latin America, CEE/CIS, and East Asia and Pacific has been quite spectacular. Most countries in these regions and in North Africa and the Middle East are already on track to achieve MDG #4 on reducing child mortality.
It is heartening to see a number of very poor countries with high rates of child deaths making particularly dramatic progress in reducing under-5 mortality in the last two decades. Among them I would list: Bangladesh, Bhutan, Cambodia, Laos, Nepal and Timor Leste in Asia; and Madagascar, Malawi, Eritrea, Liberia, Niger andTanzania in Africa. All these countries have reduced their under-five mortality rates by at least 50 %.
Globally, in our life time, we have seen dreaded diseases like smallpox eradicated and polio on the verge of eradication; deaths due to measles drastically reduced; goiter disappear, and immunization services for children becoming virtually universal.
Unfortunately, because of civil wars, poverty and heavy burden of HIV/AIDs, progress has been slow in sub-Saharan Africa. But even there, we have seen huge progress in the past decade.
I am particularly proud of my own country, Nepal. Four decades ago when I left Nepal to come to Dartmouth, Nepal had an U5MR of 250; but by last year, 2010, it had gone down to 50 or a reduction of nearly 80%.
What is especially remarkable is that during the last decade, when Nepal had a terrible civil war, with thousands of civilian deaths each year, destruction of infrastructure, interruption of many basic services, both child deaths and child birth rates, and even maternal mortality rates continued to decline sharply.
And luckily, Nepal, one of the least developed countries in the world, is today on track to achieve quite a few of the UN Millennium Development Goals.
Much of this progress in child survival in Nepal and elsewhere is the result of increased use of basic health interventions such as oral rehydration therapy, exclusive breast feeding, immunizations, Vitamin A supplementation, use of insecticide-treated bed nets (ITNs), and very importantly increase in girls’ education and women’s empowerment.
Now, you might legitimately ask, if such proven, low-cost technologies already exist to dramatically improve child survival and development why are they not being widely applied? What are we waiting for? What is missing?
In the world of international development, we have learned that existence of proven technologies, cost-effective solutions and common sense approaches are not enough. We also need visionary leadership, strategic management and popular participation for common-sense programmes to be widely applied.
I have had the good fortune to work for over 3 decades with one of the most effective branches of the United Nations, UNICEF, in a global movement for child survival and development which embodied these elements of strategic management and popular participation, initially under the inspiring mentorship of an amazingly charismatic and visionary leader named James P Grant.
This evening, I would like to share with you some highlights of what I learned, and how we can make child survival the cutting edge of human rights and human development.
Jim Grant was one of the true giants of public health in the 20th century. He was a quintessential humanist and development professional. He came from a family of medical missionaries. His father John Grant was a pioneer of a public health approach in China that came to be known as “barefoot doctors”, and later became the inspiration for what is now known as the primary health care approach.
During 15 years of Grant’s leadership, UNICEF articulated and led a movement for child survival and development with relentless energy and unflagging commitment. It made child survival not just a health issue, or a development issue but a matter of children’s human rights with great political appeal and payoffs for wise political leaders.
UNICEF helped devise a unique strategy emphasizing simple, low-cost, low-tech interventions like immunization, breastfeeding, growth promotion, and oral rehydration therapy that could produce quick and tangible results.
The genius of this approach was to demonstrate the power of skillful advocacy, communication and social mobilization to take public health to the door-steps of ordinary people on a massive scale.
When he took up UNICEF’s leadership, Jim Grant found it unconscionable that 15 million children were dying every year – 40,000 everyday – in a world which had the knowledge and means to prevent most of those deaths.
He led UNICEF to advocate for a massive increase in coverage of such life saving interventions as immunization and oral rehydration therapy.
Immunization coverage in developing countries was less than 20 percent in the early 1980s. UNICEF argued that the world needed to increase it to 80 percent by 1990. Many thought that such an increase was unrealistic. Indeed, if we followed the normal incremental approach such acceleration would have been impossible.
Most ministries of health did not have the manpower, financial resources and organizational outreach to make a quantum jump in immunization services. Recognizing this, UNICEF developed a two-pronged strategy to overcome this constraint.
On the one hand we 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 at minimal financial cost.
On the other hand, UNICEF would approach religious leaders, the mass media, film stars and sports personalities, and non-governmental organizations, to promote immunization, ORT and other child survival actions.
We enlisted Audrey Hepburn and Peter Ustinov, the James Bond Roger Moore and football star Pele, singer Harry Belafonte and actress Vanessa Redgrave, as we do today with Roger Federer and Ricky Martin, Shakira, Bono and Angelina Jolie to promote the cause of child survival and human development.
Such outreach and social mobilization greatly reinforced and energized the usually weak and lethargic health ministries.
As a result, 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.
Grant was masterful in generating a healthy competition among countries, provinces and municipalities to outperform their neighbours. If an economically poor country like Sri Lanka could reduce infant mortality to a low level why was not a much richer country like Turkey or Colombia or Indonesia doing better?
UNICEF used such public comparisons not to humiliate countries but to motivate them.
In the name of child survival, UNICEF was even able to help stop wars and create “corridors of peace” and “days of tranquility” to immunize children and provide other basic services.
In the mid-1980s Grant persuaded the President of El Salvador and got the Archbishop of San Salvador to broker an agreement with the leftist rebels to stop the war for a few days each year so health workers could travel throughout the country, without any restrictions or fear, and vaccinate children.
Such “days of tranquility” became a model and were used in many countries at war, including Afghanistan, Angola, Burundi, Congo, Lebanon, Sri Lanka, Sudan, and elsewhere, including in the polio eradication campaigns of recent years.
In the name of child survival, UNICEF was able to convene the largest gathering of leaders in history, the 1990 World Summit for Children.
I personally had the honour to help draft the Declaration and Plan of Action of that Summit which adopted ambitious and measurable development goals for children. It was that Children’s Summit which paved the way for the major world conferences and Summits of the 1990s on population, environment, women and development, etc. culminating in the historic Millennium Summit in 2000.
Indeed, the origins of today’s Millennium Development Goals can be traced back to the goals originally set by the World Summit for Children.
The child survival and development revolution that UNICEF spearheaded under Jim Grant’s leadership, between 1980 and 1995, was credited with saving the lives of an estimated 25 million children, protecting the health of millions more, and putting child rights high on the political agenda of the world.
There were some critics who argued that Jim Grant and UNICEF over-simplified the world’s development challenges by boiling them down to just a few vertical, 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?
Those of us who knew and worked with Grant knew that far from being simplistic and narrowly focused, he had a broad and holistic vision of development. UNICEF was very aware of the multi-faceted nature and complexities of development. We 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.
UNICEF 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, accelerating economic development, and promoting democracy by empowering people.
Let us not forget that nothing is more disempowering to parents than to see their children die. Inability to save and care for 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. Once basic health is assured, parents begin to demand basic education, water and sanitation, nutrition and other social services. Thus starts a virtuous cycle of empowerment and upward mobility.
Child survival need not be – must not be – a matter of charity or simple vertical medical interventions. When pursued by unleashing the power of social mobilization, moral persuasion and behaviour change, it can become a powerful force for social transformation.
Now, many of the diseases that kill children in developing countries are also found in the rich countries.
It is not uncommon for children in rich countries also to get diarrhea, pneumonia and infections of various kinds. But because they have proper immunization, better nutrition, and access to clean water and sanitation, children can withstand these diseases and do not die.
But the same diseases and infections can be fatal in poor countries.
In other words, it is not really diseases that kill, it is poverty that kills children.
The association between poverty and child mortality has long been recognized.
Indeed in poor countries and communities, U5MR is often an excellent proxy indicator for the measurement of poverty.
Today over 75 percent of the world’s child deaths occur in 15 countries, and about half in only 5 countries – India, Nigeria, DR Congo, Pakistan and China.
These same countries also account for the vast majority of maternal deaths, malnutrition and lack of safe drinking water and sanitation.
Indeed, much of the world’s greatest tragedies befalling children are concentrated on the bottom billion people of the world, who subsist on less than $1 a day.

Please close your eyes for a moment, and imagine what would you do if your income was just $1 a day, or $5 for a family – for food, for shelter, for clothing, for education, for health care, for festivals and for funerals?
It is such degrading poverty that kills millions of children; that keeps them out of school and throws them into child labour.
It is poverty, debt and unemployment that lead desperate parents to even sell their vital organs like kidneys through unscrupulous middle-men to provide for their children.
And when all else fails, parents are even forced to abandon their children, sell them to brothels or bonded labour to work in slave-like conditions.
Because children bear the heaviest burden of poverty, all efforts to combat poverty must give the highest priority to children.
Now, some say that poverty has always been with us, and it will never be completely eliminated. That maybe true in the case of relative poverty, but we simply cannot and should not accept the indignity of absolute poverty as the unavoidable fate of humanity in this world of incredible wealth and prosperity.

Along with the issue of poverty, we now need to deal with the issue of equity. In all countries, rich and poor, the greatest concentration of ill health, illiteracy, malnutrition and child deaths are now disproportionately concentrated among the bottom quintile of the population. Under the leadership of its new Executive Director, Anthony Lake, UNICEF has now devised many practical strategies to reach the hard to reach, the marginalized and excluded children. Deliberate efforts to reach this segment of the child population on a priority basis, is not only morally right, but increasingly practically feasible and financially affordable. We must therefore spare no effort to leave no child behind.

The time has come for all of us, to consider the struggle for child survival and the fight against child poverty everywhere, in rich as well as in poor countries, not as a matter of charity, but as a matter of human rights, and a foundation for human development.
Yes, besides child survival, the world has many other problems, and Dartmouth has many other priorities. But most other problems can wait, children cannot. They have only one chance to grow – and we all have a duty to help them survive and thrive.

Thank you.