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Global Health in Transition: A Synthesis: Perspectives from International Organizations The State of the World's Children, 1994 and 1995 Grant, JP. 1994 and 1995. The State of the World's Children. New York: Oxford University Press. This series of annual reports presents a compilation of well-referenced, all-country statistical tables on basic indicators, nutrition, health, education, population, economic progress, and the situation of women. It includes regional summaries of those statistics, basic indicators for less populous countries, and a variety of analytical graphics. It also assesses progress toward established program goals, including components of the Child Survival Initiative and the goals set at the 1990 World Summit for Children. All of this information is scrutinized in the context of the larger social and economic forces that have positive or negative impacts on the data presented and on the overall well-being of children worldwide. OBJECTIVES To summarize progress against the major specific threats to the health of children in the world's poorest communities and outline the potential for further significant advances in the years immediately ahead. To focus attention on the persisting challenge of poverty, population growth, and environmental degradation, of such grave potential that they cloud humanity's prospects for the 21st century. CONCLUSIONS Significant advances have been made against major threats to the health and well-being of the world's children: decreases in the number of deaths among children under age 5, cases of measles and polio, and total fertility rates; and increases in the number of 1-year-olds protected against vaccine-preventable diseases, percentages of
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Global Health in Transition: A Synthesis: Perspectives from International Organizations married women using contraception, and the level of primary school enrollment. Progress in these areas depends not just on economic development but also on sustained commitment to improvements in the well-being of the poor; yet, only small proportions of government expenditures and foreign aid are devoted to basic human needs in health, nutrition, education, and family planning. Given greater priority, child malnutrition, disease, disability, and illiteracy could be drastically reduced by the year 2000. That potential is threatened, however, by extremes of deprivation, exploitation, and abuse of children everywhere and by the poverty/population/ environment spiral, in which the worst aspects of poverty propel rapid population growth and environmental degradation, which circle round to exacerbate poverty. Conversely, mutually reinforcing investments in health, nutrition, basic education, and family planning can create an upward and synergistic spiral of improvements in well-being that would help reduce population growth and alleviate environmental stress. Absent this, social division, economic disruption, political unrest, and reversals in progress toward democracy and international stability can only continue to occur. Sub-Saharan Africa is a special case, sliding back into poverty at an average annual rate of 2 percent of per capita gross national product in the 1980s. The population of almost half of the region is now in absolute poverty; malnutrition has quintupled in some areas; health services have declined, despite heroic efforts in immunization; primary school enrollment has fallen; and one-third of all college graduates have left the continentall in the context of the AIDS epidemic, conflict, environmental degradation, and population growth. Improved health is a powerful weapon for attacking poverty, as judged in terms of the economic losses due to specific diseases, returns to investments in water supply, increases in productivity and decreases in lost labor time, greater returns to other forms of investment, decreased medical costs, long-term effects on population growth, or the profound connection between the mental and physical development of children and the social and economic development of their societies. Education, particularly for females, means fewer and better-spaced births of offspring who are more likely to survive, be better nourished, and become educated, as well as greater overall capacity for ensuring better family health and managing the environment. Family planning is a major contributor to lower mortality rates among children under age 5, which, in turn, contributes to greater demand for
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Global Health in Transition: A Synthesis: Perspectives from International Organizations family planning and significant improvements in health, survival, nutrition, education, and quality of life for both mothers and children. RECOMMENDATIONS FOR POLICY AND ACTION The central organizing principle of the post-Cold War era must be managing a transition to a sustainable future, an essential part of which is coming to grips with the great crises of poverty, population growth, and environmental deterioration. Because of their complexity and the synergy among these crises, the developed nations must move cooperatively, with a new ethic of progress, on several broad fronts. Creation of an enabling economic environment through agreements on fair and stable commodity prices; more open access to markets for manufactured exports; forgiveness of significant proportions of debt in selected regions and cases; more investment in the health, nutrition, education, and employment of the poorest eople; rapid progress toward at least primary education for all children, especially for girls; improvement of the lives of women in poor communitiestheir health, education, and status; and making available family planning information and services to all who need them. Intensive research efforts, in cooperation with scientists and technicians from developing countries, to develop economies and technologies that can raise living standards and fulfill legitimate aspirations without endangering the biosphere. New definitions of progress in developed countries that maintain or improve the quality of life yet significantly reduce impacts on the environment. Articulation of a special strategy for Africa: Debts must be written down. The region's trading position must be allowed to become stronger through lower trade barriers to its processed and manufactured goods, creation of an economic diversification fund, and increased aid and investment.
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Global Health in Transition: A Synthesis: Perspectives from International Organizations Military spending by African governments and by those who export arms to the region must decline more steeply. African governments must make good on their commitments of greater proportions of revenues to human resources and to basic goals in health, nutrition, education, and family planning. The international community should assist Africa in its struggle toward democracy through direct assistance to those policies and institutions that deepen democracy's foundations. COMMENTARY The State of the World's Children points to the considerable progress made in fighting the diseases that kill and disable children and lists those that are in retreat: measles, tetanus, polio, diarrhea, and iodine and vitamin A deficiencies. However, it notes other problems: the extreme deprivation and exploitation of children and the abuse of children in war, in the workplace, on the street, and at home, which afflict millions of children everywhere. Even here, however, the report notes a few tentative signs of an emerging new ethic that might one day offer children protection from the perils of the adult world. Still, achievements in the health of children and the promise of further achievement can only be seen as fragile, set as they are in what the United Nations Children's Fund (UNICEF) terms the poverty/population/environment spiralthe complicated dynamic among poverty, population growth, and environmental degradation. UNICEF sees the global management of that spiral and emergence to a sustainable future as the most complex, difficult transition in all human history. The responsibility for that management falls to both the developed and developing countries. The most difficult challenge for the developed world will be a redefinition of its own concepts of growth and progress. If the transition is to be made, the developed world will also be challenged by a continuing need to play a major part in helping to resolve the problems of poverty, population growth, and environmental degradation in the developing world. A central point of UNICEF's argument is that it is hard to imagine this occurring in any way but cooperatively and with a fresh definition of progress. In the context of this Synthesis, we are aware of UNICEF's perspective, that is, to locate ourselves along the paths of developmental progresson the one hand, to be certain of victories that are being achieved, and on the other hand, to ready ourselves for new challenges, particularly when they involve transitions to different kinds of problems requiring entirely different responses.
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