It was good to learn from Richard Smith that he is applying his talents at the United Health Chronic Disease Initiative and shared with us his impressions of the Conference in New York on the Millennium Developmental Goals. (MDGs)

Most of the MDGs relate to children – the goals are useful in as much they have focused on the problems but by isolating as ‘targets’ interrelated problems they are unlikely to solve the basic issues and thereby create a culture of failure.

There is no one solution but we need to work up from families and communities and encourage the ‘will’ of all the national leaders for them to realize they have the solution in their own hands.

The current global financial problems provide an opportunity to reflect on how money can be invested for the future . The significant ‘correction’ over the last year has slashed more than a third off the reserves of many institutions. The widening gap between the rich and poor nations increases this global instability Most fund managers have previously focused on short term gains to get a quick fix for their quarter quotas without taking the long term view. But what we really need to do is to take a wider view and reflect on where the value of investment lie. It is in people.

The most dramatic illustration of this is the difference between the number of children dying under the age of five for each 1000 births between the countries of the world. This under five mortality rate is a sensitive index on the value placed by nations on their children. A few years ago Sweden was top of the international table with an under five mortality rate of 3 per thousand love births. Bottom of UNICEF’s ‘league’ table was Sierra Leone with a rate of 314 children dying under the age of five. – nearly one third of their children ! What a devastating impact this is having on the future of that country.

Children are a country’s future. Healthy children attend school, become healthy and productive adults and improve the economic wellbeing of their country
. They also lead a healthier old age

Poverty breeds disease and disease causes poverty. Disease in just one family member may have disastrous effects on the children through loss of care and reduced family income causing older children to leave school to support the family. The tragedy of the AIDS orphans is all too apparent in Africa.

Poor families compensate for children’s deaths by having a large number of children with the expectation that sufficient will survive to care for the parents in their old age. Large families simply cannot afford education and health care for each child. Conversely reduction in mortality can be a spur to reducing fertility rates. The evidence linking fertility levels to infants under the age of 1 yr and child mortality under 5 is powerful. Countries who have an infant mortality rates of les than 20 have an average total fertility rate of 1.7 children. In countries where the infant mortality rates of over 100 have an average total fertility rate of 6.2. children. This confirms the studies undertaken 25 years ago in nine different countries on the Value of Children. When children are valued in their own right rather than for utilitarian purposes, family size is smaller.
The mothers education is clearly another important factor but one which is also associated with the family’s increased earning capacity. The clear message is that looking after children means less and not more mouths to feed, better education , healthier adults and improved economic progress

The main cause of children worldwide dying under age the age five years are malnutrition, malaria measles, diarrhea, respiratory illness and AIDS. All are preventable. All are treatable. The impact of controlling these diseases in Sub Saharan Africa would be dramatic Historically the virtual elimination of malaria in several subtropical regions in the 1940s and 1950s had a ‘galvanizing’ effect on economic growth spurring massive tourism and foreign investment. Such gains would greatly exceed the direct costs of the disease as would have been measured in a ‘cost of illness’ study .

The risks to commercial enterprises of AIDS in sub Saharan Africa seems to be taking an enormous toll on investments in the region. With the massive turnover resulting from AIDS, firms are constantly facing the breaking up of work groups and the heavy cost of re-training workers. Indeed some more enlightened companies are finding it cost effective to provide the appropriate treatment for their workers Something that would also apply to Governments !

When a significant number of people become ill in a community, the whole community suffers. An money available is often shifted to care for the ill reducing the amount available for preventative and supportive health social services. The level of trust within the community may fall especially if the disease is interpreted as a curse as frequently reported in parts of Africa in response to AIDS. Skilled workers may flee leaving the community leaderless without the necessary drive and technical expertise.

The high burden of disease disrupts national budgets in the same way as the family budget . The health care systems are overwhelmed and require more resources. Tax revenues collected by governments are reduced as the economic activity is diminished with the decline in tourism and new business development. This combination of reduced budget revenues with increased budget demands tends to lead to budget deficits that in turn can destabilize the macro-economy with further adverse effects on the economy of the poor countries

Well targeted investment in Heath care has resulted in significant improvements. Over the past three decades, various immunization campaigns and child health initiatives have increased by millions the number of children protected against common childhood infections. But the burden of preventable disease in poor countries remains unacceptably high. Measles is still a major killer -800,000 deaths in 1998. It has been estimated that by 2010 around 8 million lives per year could be saved by essential interventions against infectious diseases and nutritional deficiencies.

The Poverty reduction Strategy Framework is a good start as it provides a comprehensive approach explicitly incorporating local civil societies at each step with more door co-ordination in support of the country’s goals. The Commission on Macroeconomics and Health reporting to the World Heath Organization suggested that each country should define an overall programme of ‘essential interventions’ to be guaranteed universal coverage through public and door funding. Four main criteria were suggested. The interventions should be 1. Technically effective and deliverable. 2 Involve diseases causing the greatest burden of illness 3 the social benefits should exceed the cost of the interventions 4 the needs of the poor be stressed.. The Commission estimated the cost of these essential interventions on a per capita basis to be #34 per person per year. A modest sum especially when compared with the average per capita health spending in high income countries of more than $2,000 per year. The least developed poor countries can mobilize around $15 per person per year. The gap is $19 per person per year ! With the 750 million people in the poor countries in 2007 that adds up to $14 billion. Not much more than tobacco companies extract from their cigarette smokers each year to advertise their death dealing products globally !

In Africa, many households spend significant sums of money on traditional forms of ‘therapy’ often with disastrous result. Others pay for good treatment at private and faith based facilities. Public expenditure can also be misdirected and wasteful especially when too much funding goes to prestige high tech curative services for the ‘urban elite’ in the nations capital cities.

There are well trodden paths to progress. The increased resources required must come from a combination of government funding, private domestic expenditure, faith based organizations, other non governmental initiatives, external official development assistance from the rich nations and industry especially the pharmaceutical companies..
Pharmaceutical companies need to build on their commitment to provide essential medicines in the low income countries at the lowest viable commercial price.

The rich nations need to invest more in official development assistance. The total Gross National Product of the ‘donor’ nations is around $525 trillion per year (2001). The total development assistance is around $53 billlion, or 0.2% of gross national product of the donor nations. The International ‘standard’ recently endorsed by the International Monetary Fund and The World Bank is 0.7 % of GNP. Only five donor countries subscribe at that rate. In 1999 the UK subscribed 0.23% and the United States 0.1%. Ireland and the United Kingdom are committed to invest the recommended 0.7% in the future. If others followed with this investment and it was targeted at the most needy children our future economic health and social wellbeing will be safeguarded

James Appleyard
Kent

And a few of us who still have reservations about the morality of Clinton’s tenure would even question the appropriateness of having him as a keynote speaker at a conference such as this. Here’s one view of the Clinton legacy that I find hard to refute: http://www.prorev.com/legacy.htm