Child Health and Human Rights: Making the “Impossible” Possible

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



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Child Health and Human Rights Child Health and Human Rights: Making the “Impossible” Possible 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

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Child Health and Human Rights 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.

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Child Health and Human Rights 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;

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Child Health and Human Rights 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.

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Child Health and Human Rights 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

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Child Health and Human Rights 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:

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Child Health and Human Rights 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

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Child Health and Human Rights 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.

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Child Health and Human Rights 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

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Child Health and Human Rights 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.

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Child Health and Human Rights 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!

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