Child Health and Human Rights (1994)

human rights in the United States and elsewhere.

On the evening of March 10, 1993, the IOM Committee on Health and Human Rights invited James P. Grant, executive director of the United Nations Children's Fund (UNICEF) to address the topic of child health and human rights at the National Academy of Sciences in Washington, D.C. This lecture marked an important transition in the human rights activities of the Institute of Medicine. Although casework on behalf of health professionals still lies at the heart of our human rights work, we realize that we must also address the special health needs of vulnerable populations who are victimized by war and civil disorder. When these victims of oppression are groups of women and children rather than individual well-known physicians, the nature of the human rights violations may be extremely difficult to document and assess, and our responses are often challenged by incomplete or contradictory information and the absence of reliable indicators or sources of expertise. Our response is also complicated by the absence of a conceptual and legal framework that can provide a clear rationale for humanitarian interventions that take precedence over national sovereignty.

Through casework experience, however, we have learned that health professionals do have valuable skills and resources that can be applied effectively in addressing human rights violations. Physicians, nurses, and others can document individual cases of torture or the systematic use of violence (e.g., patterns of injury that corroborate deliberate violence directed against an individual or population group). Because of the international nature of our professional and collaborative efforts, health professionals can often elicit information from colleagues who treat such injuries and who cannot speak out locally without fear of recrimination. We have the capacity to collect diverse facts and prepare analytical reports that highlight key trends, data, and indicators of the nature of human rights abuses. In some cases, research fields such as genetics, forensic science, statistics, and other disciplines can make direct contributions by documenting the occurrence and scope of human rights violations. Such evidence can sometimes be valuable in investigative or legal proceedings organized by international human rights tribunals.

Health professionals also possess a great deal of expertise and experience in the development of humanitarian relief efforts. Access to public health care and medical services in a wide range of areas—sanitation, potable water, sufficient nutrients, treatment of diarrheal diseases, and the vaccination of children—is essential to prevent public health disasters.

The challenge before us is to devise ways that draw on our expertise effectively in situations characterized by conflict, uncertainty, and controversy. To meet this challenge, the IOM Committee on Health and Human Rights initiated a professional educational endeavor, of which this lecture is the first step. This undertaking is designed to stimulate discussion and reflection on the fundamental dimensions of the evolving framework for health and human rights, focusing on the following questions:

• What international legal standards guide and support the human rights concerns of health professionals?

• What is the relationship of these international standards to the humanitarian relief concerns of health professionals?

• What course of action is appropriate for organizations such as the Institute of Medicine in responding to the special health needs of vulnerable populations who suffer deprivation as a result of war or internal conflict?

The collapse of communism in the Soviet Union and other parts of the world has fostered democratic changes in many regions, but it has also become a dangerous source of political instability. In some regions, the disintegration of stable governments has given way, to anarchy, civil disorder, and internal conflict, spawning waves of refugees and immigrants replacing the heroic political dissidents who formed the focus of our human rights concerns in the past. A search for effective mechanisms to resolve tensions involving nationalism, ethnic hostilities, and civil chaos has fostered a new legitimacy for military interventions designed to ease human suffering and to restore political stability. The new concept of “humanitarian intervention ” has been bolstered by internationally sanctioned efforts designed to enforce the humane treatment of citizens during periods of political turmoil.

In this new framework of humanitarian interventions, the role of private human rights organizations has become more complicated and uncertain. The emerging power of international human rights law has created a multitude of opportunities as well as challenges for organizations that have traditionally been concerned with a narrower scope of human rights activity. Because these groups are unaccustomed to serving large numbers of victims, they may be overwhelmed by the extent of the suffering of civilian populations. In order for private human rights organizations to operate effectively, a broad set of issues must be addressed by the health research community. Examples of such issues include the clarification of operating principles that should govern access to health resources by populations at risk for violence; the appropriate definition of medical neutrality for professionals who provide services to citizens in regions affected by civil disorder and violence; the quality of health care services for prisoners, refugees, and displaced populations; the use of international legal sanctions and military force in ensuring compliance with humanitarian standards; the appropriate means of delivery of effective health services for vulnerable groups, especially women, children, the elderly, and the disabled, in regions characterized by chronic violence and deprivation; the physical and psychosocial effects of

violence and deprivation on human development; and the role of medical and forensic sciences in documenting the abuse of power, especially torture, executions, and inhumane treatment of prisoners and civilian populations.

In addressing these issues, we have chosen to begin with the topic of child health. This choice has been guided by several principles and resources. First of all, a new International Convention on the Rights of the Child has been developed and ratified by 171 countries as of March 1994 and will soon be considered for ratification by our own Congress. The issue of child health and its relationship to the legal rights of the child, therefore, represents an important opportunity to consider the relationship between an emerging international legal standard and our own professional practice.

Second, the deprivation and health needs of refugee children in various countries throughout the world have caught our attention repeatedly as we have witnessed the human suffering resulting from conflicts in Iran, South Africa, Bosnia, El Salvador, Somalia, Haiti, Rwanda, and elsewhere. The health and well-being of children in such situations are often important indicators of the welfare of an entire population, for if basic health services are denied to the most vulnerable group of a society, there is little doubt that adults will suffer as well. And the effect of increases of child mortality in any society are devastating to the families and their community.

Finally, the area of child health is one in which the Institute of Medicine has acquired some special expertise as a result of a broad range of studies and workshops conducted in recent years. The IOM maintains an active program of studies related to child health and well being. In 1993, the Commission on Behavioral and Social Sciences and Education (CBASSE) and the IOM joined to establish a new entity, the Board on Children and Families, to provide a permanent and highly visible locus within the National Academy of Sciences for promoting a more effective alliance between those who produce scientific knowledge about children and families and those who use it to shape policies and programs.

A number of specific IOM studies address child health issues (see Appendix D). In order to explore an important issue in the national health care reform debate, for instance, the IOM held a workshop in July 1994 on issues relating to women and children under health care reform. An earlier report anticipated the national health care reform debate and identified a number of specific health policy goals for pregnant women and children. A 1993 report explored the adequacy of emergency medical services for children in the United States, and suggested ways to make both services and systems more appropriate for children 's needs. Finally, another IOM committee is currently evaluating the nutrition risk criteria of the Special Supplemental Food Program for Women, Infants, and Children (WIC).

In December 1993, the Board on Children and Families also conducted a workshop on overcoming barriers to immunization. This workshop explored and

clarified the difficulties in immunizing young children, discussed efforts to overcome the problems, and served as a neutral venue to examine many of the current proposals for improving immunization coverage. A series of projects initiated by the 1986 National Childhood Vaccine Injury Act assessed the scientific and medical literature bearing on the causal relation between childhood vaccines and serious, adverse health outcomes. The information in these reports has been used by the Department of Health and Human Services to shape its national vaccine injury compensation program.

An IOM report issued in 1991 evaluated the justifications for and appropriateness of screening newborns and pregnant women for HIV infection, taking into account the technological, medical, epidemiological, social, and ethical factors. Another congressionally mandated study is currently addressing the prevalence of Fetal Alcohol Syndrome and related conditions in the United States and the adequacy of federal efforts to reduce the incidence of such conditions.

In recent years awareness has been growing of the poor record of the United States in fostering the health and social well-being of its children. It is a national disgrace that in the midst of our economic affluence we have such poor levels of infant immunization and prenatal care, resulting in inadequate child health status and child mortality. We have achieved tremendous progress in protecting our children from polio, whooping cough and other childhood infectious diseases, but without more complete immunizations, the picture will change, as it did for measles. Many American children today are not being immunized against traditional childhood diseases, not because our society lacks the resources for immunization, but because we have not committed ourselves to a public health strategy that stresses the importance of interventions directed toward improving the health status of all children.

We must do better in protecting and supporting our sons and daughters. There are signs of progress that we need to examine and build upon. The U.S. government report A Culture of Caring, for example, represents a powerful document that could provide a strategic plan to implement many of the health goals of the International Convention of the Rights of the Child. Other reports, such as the 1993 World Development Report Investing in Health prepared by the World Bank, provide important indicators and statistics that measure the comparative burden of selected diseases on children and other age groups. In 1993, a UNICEF report observed that tremendous progress has been made in the last 50 years in addressing infant and child death rates, increasing life expectancy, and providing access to safe water for rural families. However, there

is still much that needs to be done; UNICEF has estimated that an additional $25 billion a year is needed to meet the health, nutrition, education, and water and sanitation goals agreed to at the World Summit for Children plus resources for family planning goals. On average, less than 10 percent of the $40 billion a year in official development assistance (ODA) is devoted to basic social needs, amounting to $4 billion per year, about the same amount that our country alone pays for sports shoes each year.

As health professionals, we know that disease prevention efforts such as immunization, prenatal care, behavioral interventions, screening, and so forth, are preferable to waiting for disease and infection to start before offering treatment interventions. We also know that we have a responsibility to improve our ability to diagnose accurately and to recommend appropriate treatment for illness when prevention fails.

In considering the health and welfare of children today, we need to recognize that other lethal threats have taken the place of disease and infection as killers of the young. The health of children in America today is increasingly threatened by guns and violence as well as disease or infection. In 1989, the National Committee for Injury Prevention and Control stated that child homicide is now among the five leading causes of death in childhood, accounting for one in every 20 deaths of people below the age of 18. In 1991, the National Center for Health Statistics indicated that over 4000 children age 0–19 were murdered in 1991 alone.

In addressing the experiences of children whose lives have been affected by violence, we cannot lose sight of the complementary roles of prevention and treatment. The global statistics are staggering—officials from the UN High Commission on Refugees estimate that there are currently 20 million refugees, 10 million of whom are children. We increasingly see child residents in refugee camps, including refugee centers in the United States.

How can we prevent such human tragedy? How can we treat such children effectively when prevention mechanisms for conflict resolution and the promotion of peace are so inadequate?

One important step is to begin to mobilize awareness of and support for the U.S. ratification of the International Convention of the Rights of the Child. A second step is to address more forcefully the issues of equity and access to health resources that are central to discussions of global health care. A third is to examine with care the development reports of the United States government, the World Bank, and other international institutions and to understand the assumptions and rationale that guide strategic plans for international health investments.

The challenge of making disease, injury, and violence prevention a worldwide mission in the interest of protecting children is a daunting task. But in this report we begin with an important asset—the expertise and insight of James P. Grant, who has been a forceful leader for decades on behalf of children throughout the world. It is our pleasure to introduce him as a champion of child health and human rights. We look forward to learning from him and to using his insights as a foundation for our own efforts in responding to the challenges that lie ahead.

Elena O. Nightingale, M.D.

Chair, IOM Human
Rights Lecture Program

Robert S. Lawrence, M.D.

Chair, IOM Committee on
Health and Human Rights

James P. Grant

Executive Director, United Nations Children's Fund

I am delighted and honored that you have asked me to present the first in your new series of lectures on health and human rights. You have asked me to focus on the status of children worldwide, and to answer the question: What happened to hope?

The famous social critic H.L. Mencken once called hope “a pathological belief in the occurrence of the impossible,” and I confess that my goal here today is to transmit this ever so benign pathogen to each and every one of you, and to this distinguished medical institution. Hope can be rather contagious—if conditions are ripe, as they seem to have become in Washington of late. So I trust we'll be able to get a little epidemic of hope going here this evening. May it spread quickly, far and wide!

Most of our work at UNICEF is with the developing countries, and you may well ask what is it that gives me hope about the future of children, particularly among the world's over one billion poor. The popular impression conveyed by the media is that the developing world is a stage upon which no light falls and only tragedy is enacted. But the fact is that, for all the setbacks, more progress has been made there in the last 50 years than in the previous 2,000. Since the end of the Second World War, average real incomes in the developing world have more than doubled; infant and child death rates have been more than halved; average life expectancy has increased by about a third; the proportion of the developing world's children starting school has risen from less than half to more than three quarters (despite a doubling of population); and the percentage

of rural families with access to safe water has risen from less than 10 percent to almost 60 percent.

Yet even these extraordinary statistics cannot capture the true dimensions of the change that has occurred in only a few decades. The world has also freed itself from colonialism, brought apartheid in all its forms to the beginning of the end, and largely freed itself from the iron grip of fascist and totalitarian regimes. And underlying all of these changes is the slow and even more fundamental change from a world organized almost exclusively for the benefit of a privileged 10 percent or 20 percent, as through history in most societies, to a world in which the needs and the rights of all people are increasingly recognized.

Only a few decades ago, it did not seem a matter of great concern that the poor majority had no right to vote, no freedom of expression or religion, no right to due process of law, or that their children were not educated or immunized and received little or no benefit from advances in hygiene and health care. In many nations, it even seemed natural that the children of the poor could be sold or bonded or made to work 14 hours a day in field or mine or factory.

Seen from this longer perspective, the fact that two thirds of the world's people now have the right to vote, or that more than 80 percent of the world's infants are fully immunized, or that health care is now a right codified in international law, or that there is now such a thing as a worldwide Convention on the Rights of the Child—are all symptoms of a remarkable change—and in the face of such progress, pessimism is a sign less of sagacity than of cynicism. In the decade ahead, a clear opportunity exists to make the breakthrough against what might be called the greatest obscenity of our time—the needless malnutrition, disease, and illiteracy that still cast a shadow over the lives, and the futures, of the poorest quarter of the world' s children. Each week, the lives of a quarter of a million children are taken from us—more than any war, any natural disaster has ever taken in a comparable period.

Writing some fifty odd years ago, the historian Arnold Toynbee captured the essence of the new potential brought by science and technology to our time. He said then:

Our age is the first generation since the dawn of history in which mankind dared to believe it practical to make the benefits of civilization available to the whole human race.

Years later, the Reverend Martin Luther King said essentially the same thing:

Why should there be hunger and privation in any land, in any city, at any table, when man now has the resources and the know-how to provide all mankind with the basic necessities of life? There is no deficit in human resources; the deficit is in human will.

The Italian novelist and Holocaust survivor Primo Levi took Toynbee 's and King's reasoning one logical step further in this era of increasing capacity, saying that:

If we can relieve torment and do not, we become tormentors ourselves.

These quotes, I believe, eloquently articulate a new ethos that has evolved over the past half-century out of the increasingly synergistic interaction between democracy and technological progress. Modern commerce, finance and transport, communications and media, on the one hand, and the environmental crisis and movements of refugees, on the other, have transformed the world into a global village infused, increasingly, with democratic ideals if not consistent democratic practice. And within the global village, more attention than ever before in history is being paid to the individual, his or her rights and his or her condition.

The vast disparities in standards of living and in levels of freedom and participation that have existed historically and still separate the neighbors who live side by side in this global village are increasingly intolerable to the have-nots and increasingly disadvantageous to the haves. As our capacity to do good has increased, it is gradually becoming unacceptable ethically not to use that capacity, or to exclude nations, communities or individuals from the benefits of progress. Morality marches with changing capacity.

Permit me to illustrate with two very different examples. The first is the entirely new capability that has been developed to put a bubble of protection around the first, highly vulnerable years of each and every one of the world's children. For a decade, national health services, UNICEF, the World Health Organization (WHO) and many thousands of individuals and organizations (most notably Rotary International) have struggled towards the goal of 80 percent immunization coverage of infants in the developing world. In 1990, that goal was reached. The result is the saving of over 3 million children's lives each year and the protection of many millions more from disease, malnutrition, blindness, deafness, and polio. At the same time, the number of child deaths from diarrheal disease has been reduced by over 1 million a year through empowering one third of the developing world's families to use the technique of oral rehydration therapy.

The significance of these achievements goes beyond even the extraordinary numbers of lives saved and illnesses prevented. Eighty percent immunization means that approximately 100 million children are being reached by a modern medical technique on four or five separate occasions during their first year of life. As a logistical achievement, it is unprecedented; and it shows beyond any doubt that the outreach capacity now exists to put the most basic benefits of recent scientific progress at the disposal of the vast majority of the world's poor. It also demonstrates that, with sustained political commitment, progress can now be made towards basic social goals even by the poorest of developing countries;

over the last five years, immunization coverage has been increased dramatically in many nations with per capita incomes of less than $500 a year, highlighting the extremely low cost of the package of childhood interventions.

Other advances in knowledge and technique are now lining up outside the door that immunization has unlocked. And the potential remains enormous. Thirty-five thousand children under five still die in the developing world every day—well down from the daily death toll of 70,000 in 1950, but even more of an obscenity given the progress that has taken place since. Almost 60 percent of those deaths, and much of the world's illness and malnutrition, are caused by just three diseases—pneumonia, diarrhoea and measles—all of which can now be prevented or treated by means which are tried and tested, available and affordable. Even those problems which have traditionally been considered the most expensive and the most logistically stubborn—the lack of adequate nutrition, safe water supply, and basic education—are also now becoming susceptible to a combination of new technologies, falling costs, and community-based strategies.

Our new capacity to communicate—to inform and motivate—enables us to empower families, communities and governments to give the first vulnerable months and years of a poor child's life something of the protection and nurturing that is given, as a matter of course, to children fortunate enough to be born into affluence. We can, ever so briefly, “outsmart” poverty at the outset of each new life, since poverty 's worst symptoms on the individual level are also among its most fundamental causes on the social level. Economic development is undermined when millions of children suffer from poor mental and physical growth. Equality of opportunity is denied when the children of the very poor drop of school. Productivity is sapped by the time, energy, and health that is lost to diseases. Employment prospects and incomes are destroyed by disabilities such as polio or nutritional blindness or iodine deficiency. The contribution of women to economic development cannot be liberated if women remain chained to long years of child-bearing, long days of attendance on sickness, and long hours devoted to the fetching and carrying of water and fuel. Illiterate women whose children suffer high death rates are understandably slow to reduce their births, thus further weakening themselves and their children already born. In these and many other ways, poverty's symptoms help to crush the potential of the poor and perpetuate poverty from one generation to the next.

A world of difference may separate the poor of inner city Los Angeles, Mogadishua and the new poor of Moscow, but it is not difficult to see that many of the distinctions will surely seem irrelevant to the hungry, deprived and frustrated in all three places. If we continue to turn our backs on the plight of the poor, or ask them to wait patiently for better days, we will reap a whirlwind for all humankind —a political, economic and environmental whirlwind that will shake even the prosperous and long-time democracies to their foundations and condemn us to a new international order of permanent conflict and instability.

The second example of how much things have changed is the way the world reacts to humanitarian emergencies, man-made or natural disasters. In the past—and I'm not talking about the distant past—it was “business as usual” in the rest of the world when famine or violence decimated whole populations. Historically, the world has turned its back on hungry, starving people. I was in Calcutta in 1943–1944 when more than a million people starved to death in a purchasing-power famine —i.e., when grain stores were full but landless laborers simply could not pay the inflated prices for food. The British Raj did little and people dropped like flies. The great Irish potato famines starting in 1846 were similar, in that the world stood by while a million people died and another million emigrated despite the fact that bumper crops of corn were being exported, under armed guard, to Britain and America.

Large scale international relief for victims of humanitarian emergencies is a relatively modern innovation. Only over the past 40 years—with the growing capacity of television to bring images of starving people and war-ravaged communities into our living rooms—has the international community—global public opinion—moved toward the concept of a “right to food.” The recent military intervention of U.S. and other forces in Somalia, under U.N. auspices, is a right to food intervention and as such represents a major advance toward a new standard which says it is impermissible to massively and systematically interfere with a people's access to food; such interference invites military and other actions on the part of the international community to enforce the right to food.

An historic bridge has been crossed, and, I suspect, this will have a profound effect on the way we function globally, even if the Somali operation is now being cited as an “exceptional case.” The world's threshold of tolerance toward those who would deprive people of their right to survival has been significantly lowered.

I am convinced that this will lead—in the medium-term—to a major strengthening of the United Nations' capacity to deal with the complex emergencies and conflicts which, almost surely, will continue to arise over the coming years. At present, frankly, that capacity is being stretched to the limit while public expectations toward the U.N. system far outstrip our current ability to deliver. Ongoing changes in the way the U.N. operates in emergency situations can improve performance; the establishment last year of the Department of Humanitarian Affairs to coordinate the system has already made a difference. Only with sufficient resources and adequate political guidance from the governments that, ultimately, are our bosses, will we be able to act more quickly and efficiently in emergency situations—even to the point of preventing them from becoming emergencies in the first place.

What is important, however, is not to despair as we rush from one trouble spot to another trying to put out fires. These tragedies do not define the character of our times; they are retrogressions, setbacks, centrifugal currents against the

dominant historical trend toward greater global interdependence and cooperation. While we have not been able to reap the full benefits we hoped would automatically flow from the ending of the Cold War and the rise of democracy in so much of the world, we must not allow ourselves to be so distracted and frightened by outbreaks of violence and hatred, by political fragmentation and atrocity, that we renounce the peace dividend, the global assault on poverty and underdevelopment, the debt relief, the movement to protect the environment, the lowering of trade barriers and other noble efforts that are not only possible now for the first time, but which are ultimately what will prevent the endless proliferation of conflict in the future.

The extraordinary political and economic changes of the 1990s have mightily reinforced the longer-term positive trends I have been describing. The advance of democracy throughout Latin America; the liberation of Eastern Europe; the collapse of the Soviet Union; the ending of the Cold War; the signing of the Start II accord to radically cut strategic nuclear stockpiles; the spread of democratic political reform through most of Africa (including the rapid erosion of apartheid); the almost world-wide retreat from the ideology of highly centralized government control over all aspects of economic life; and the growing acceptance of the necessity of joint international action in response to both humanitarian and environmental problems have, taken together, turned the last decade of the twentieth century into a rare window of opportunity for sustaining and accelerating the dominant trends of progress of the second half of the twentieth century. These changes amount to one of the most sudden and fundamental transformations in history, holding out new hope for world peace and development.

Amidst all these changes, there is a revolution underway in the developing world with respect to children, and I would argue that it could serve as the cutting edge of global and national efforts to address the major burning issues of our time. It can be leveraged into a global movement capable of dealing a death blow to many of poverty's worst manifestations during the 1990s, it can help spur economic development and bolster democracy, dramatically slow population growth and ease the stress on the environment. It can strengthen world peace.

The extraordinary potential of children's issues to unite and mobilize political will was demonstrated at the World Summit for Children held at the United Nations in September 1990, at about the same time as the immunization goal was being reached. The summit was attended by approximately half the world's presidents and prime ministers and resulted in a set of specific commitments which, if implemented, would indeed mark the beginning of a new era of hope.

Those commitments, designed to reflect the potential of the new knowledge and the new technologies now available, were expressed as a series of specific goals to be achieved by the end of the present century. These goals include:

control of the major childhood diseases; a halving of child malnutrition; a one-third reduction in under-five death rates; a halving of maternal mortality rates; safe water and sanitation for all communities; universally available family planning services; and basic education for all children.

To give these commitments a more permanent purchase on political priority, all the countries represented at the World Summit, and many more who have subsequently signed its Declaration and Plan of Action, also agreed to draw up detailed national programs for reaching the agreed goals. As of today, such plans have been completed in 78 countries—including the United States—and are nearing completion in some 50 others. More than 50 countries have so far indicated they will restructure budgets to increase the proportion of government spending devoted to basic education, primary health care, nutrition, water, and sanitation. The drawing up and financing of such plans is inevitably a bureaucratic process, and too much should not be expected too soon. But most nations have made a start towards keeping the promises that have been made to the world's children.

This is paralleled by the unprecedentedly rapid spread of acceptance for the Convention on the Rights of the Child, which seeks to lay down minimum standards for the survival, protection, and development of all children. By treating civil and political rights, on the one hand, and economic, social and cultural rights, on the other, as equally necessary for children's well-being, the Convention eloquently puts an end to the sterile debates of the Cold War era, in which ideological adversaries championed one set of rights to the exclusion or relegation of the other—to the detriment of children on both sides of the East-West divide. The Convention was adopted by the General Assembly of the United Nations towards the end of 1989 and came into force, with the necessary 20 ratifications, on the eve of the 1990 World Summit for Children—record time for a human rights treaty.

Usually, such conventions require many decades to achieve the stage of widespread international recognition; but in this case, the Summit urged all national governments to ratify as quickly as possible and 130 have so far done so. The United States is still on the dwindling list of countries—only 30 are left—that have neither signed nor ratified the Convention; but the good news is that the new U.S. administration has indicated it will take early action to embrace this “Bill of Rights” for children. Among other rights, the states that signed the Convention (States Parties) recognize the right of the child to the highest attainable standard of health, with emphasis on primary health care, and I would suggest that you make the Convention an important instrument in the advocacy toolkit of the Committee on Health and Human Rights.

UNICEF estimates that it would cost approximately $25 billion a year to achieve in the developing countries the goals established at the World Summit for Children; $25 billion a year is less than 5 percent of the world's annual military spending. The U.S. share would be some $2 billion additional for these

programs, less than Americans spend each month on beer, and an amount which could be found in this post-Cold War era by restructuring U.S. economic and military assistance which now totals more than $15 billion annually.

Even within present resources, much more could be achieved if more priority were given to meeting the needs of the poorest. Only about 10 percent of government spending in the developing world is allocated to basic nutrition, health care, water supply, sanitation, primary education, and family planning. Furthermore, less than 10 percent of development aid is earmarked for these obvious priority human needs.

What is required now is a doubling of current expenditures and efforts so that at least 20 percent of government spending and at least 20 percent of foreign aid goes directly to meeting basic, obvious needs. Given this modest increase in resources, and a sustained political commitment in all countries to see the job through, it is possible to achieve, within a decade, one of the greatest goals that humanity could ever set for itself, ensuring a basic standard of nutrition, adequate health care, and education for every man, woman, and child on earth.

The importance of the Convention, the Summit goals, and the national programs of action that have been drawn up should neither be overestimated nor underestimated. At the moment they remain, for the most part, promises on paper. But when, in the mid-1980s, over 100 of the world 's political leaders formally accepted the goal of 80 percent immunization by 1990, that, too, was just a promise on paper. Today, it is a reality in the lives of tens of millions of families around the world.

One lesson to be learned from that achievement is that formal political commitments at the highest levels are extremely desirable if available solutions are to be put into action on a national scale. But a second lesson is that such commitments will only be translated into action by the dedication of the professional services; by the mobilization of today's communications capacities; by the widespread support of politicians, press, and public; and by the reliable and sustained support of the international community. Most of the countries that succeeded in reaching the immunization goal, including many that were among the poorest and the hardest hit by problems of debt and economic adjustment, succeeded primarily because large numbers of people and organizations at all levels of national life became seized with the idea that the goal could and should be achieved.

The question for the years immediately ahead is whether people like yourselves in all countries are prepared to breathe similar life into new goals that have been agreed on, and into the national programs of action that have been drawn up for achieving them. Only by this degree of popular participation, by the practical and political energies of literally millions of people and thousands of organizations, will the new commitments and the promises of the 1990s be given a priority in national life.

On a global scale, renewed leadership on the part of the United States will be absolutely crucial. Frankly, the United States has in the past decade been retrogressing or stagnating in many areas of children 's well-being, while much of the developing world has been making dramatic progress at a time of great economic difficulties. All that has been accomplished globally has been done with little active U.S. government leadership, except from a bipartisan Congress. Now think of what could be accomplished if both ends of Pennsylvania Avenue were to exercise, together, the kind of leadership that is needed. By increasing investment in American children and strengthening American families, and by reordering foreign assistance to reflect this new priority, the United States, the world's sole superpower, would once more set the global standard and give a major boost to human development and economic growth—and to democracy and human rights—at home and abroad.

Physicians and public health professionals like yourselves, who are keenly aware of the links between health, human rights and the broader range of issues I've touched on today, can and must take the lead in ensuring that this comes about. There is much that needs doing —and you can do it!

• First, you can help speed the Convention on the Rights of the Child through presidential signature and ratification by the Senate. The United States is now the only leading democracy in the world that has not made it the law of the land, and its ratification by the U.S. will send a powerful and hopeful message around the globe.

• Second, efforts should be made to ensure the implementation of the U.S. Program of Action for the World Summit for Children follow-up. The plan presented by the outgoing administration in January provides a welcome starting point for a bipartisan initiative for America 's children. What an inspiration it will be for the rest of the world to see the United States taking a lead in investing in its children!

• Third, you are well-positioned to argue for a restructuring of foreign assistance so that a larger proportion—at least 20 percent, as I mentioned earlier—goes to meeting priority human needs, and particularly the needs of children in the poor countries of the world. In our global village of interdependence, proliferating ethnic conflicts and environmental degradation affecting us all, such assistance is not charity but an investment, an investment in human development, economic progress, slower population growth, environmental protection, democracy and peace.

• Fourth, you and your organizations need to investigate and speak out against the unspeakable atrocities occurring in the Somalias and

former Yugoslavias of the world, where children and women have become gratuitous targets in warfare. Expert assistance is desperately needed to design and mount massive programs to assist war-traumatized children. Peace education—in schools, communities and the home—is also a necessity, so that tolerance rather than hatred may become the universal culture of humankind as we approach the twenty-first century. The events of last year in South Central Los Angeles are a sobering reminder that this kind of human and social reconstruction work needs to be undertaken, seriously and urgently, at home as well as abroad.

• Fifth, immunization. While reaching more and more infants in the developing countries, vaccines have been reaching proportionately fewer infants in some industrial countries like the United States, and we are seeing alarming comebacks and outbreaks of diseases that should have long since disappeared. The re-commitment to universal immunization that is now developing in the United States will give a truly global boost to the lifesaving effort. One critical lesson of a over decade of experience is that making vaccines available isn't enough; people need to be educated, motivated and mobilized to seek out immunization.

• Sixth, to the extent that oral rehydration therapy becomes the established priority for treating diarrhoea in the homes and hospitals of the United States, it will continue to catch on and save millions of lives in the countries where diarrhoea remains the number one or two killer of children. As leaders in medicine and public health, you can help convince practitioners and institutions of the effectiveness of ORT, while persuading public opinion that it is a “state-of-the-art ” solution.

• Finally, to the extent that you take seriously the slogan “breast is best” and help make your own practices and health institutions truly “baby friendly,” breastfeeding can make a dramatic comeback. A return to the widespread practice of breastfeeding with proper weaning practices would reduce global infant mortality by more than one million lives annually. Last year, most of the developing world took action with the cooperation of the infant formula industry to halt the harmful free distribution of formula through hospitals and maternity centers. Your active support is needed if we are to reach the goal of ending this practice in the health institutions of the industrial countries by mid-1994. I see this as a critical step toward making workplaces, communities and society as a whole more supportive of mothers, children and families.

In closing, let me say that I hope my remarks tonight have infected you with a little of my “pathological belief in the occurrence of the impossible” and that you will join UNICEF—and allow UNICEF to join you—in making it happen starting with the children!