PRB

(February 2008) Each year, nearly 10 million children die, mostly from preventable and treatable causes. Millions of children in low-income countries suffer from long-term illnesses, malnutrition, and injuries that limit their life options. What can we do to improve children’s health and save lives in low-income countries? What are the links to mother’s health?

2008) Each year, nearly 10 million children die, mostly from preventable and treatable causes. Millions of children in low-income countries suffer from long-term illnesses, malnutrition, and injuries that limit their life options. What can we do to improve children’s health and save lives in low-income countries? What are the links to mother’s health?

In a PRB Discuss Online, Dr. Nils Daulaire, president and CEO of the Global Health Council, answered participants’ questions about ways to improve child health.

February 13, 2008 1 PM EST

Transcript of Questions and Answers

Olalla Bohigas: Hello Dr. Daulaire, I’m a Geography student from Spain. I would like to ask yo if you think that a totally public-funded sanitary system improves child health and in which ways. Thank you.
Nils Daulaire: I don’t think the critical question is whether it’s totally public-funded or not. I think the critical question is whether a given sanitary system actually works to provide clean water and safely remove sewage, whether it is maintained and operationally sustainable, whether it responds to the real needs of people at highest risk of water-borne diseases (e.g. the poorest) or serves only those who are better off. In many instances, this will indeed be mostly or totally public-funded, but the devil is in the details. The ways in which a working sanitary system improves child health is in the reduction of water-borne diseases, notably diarrheal diseases which still claim 2 million lives a year, and which account for a massive impact on undernutrition.

Richard Cincotta: “Low-income” has become a broad category due to emerging differences in these countries’ progress along the demographic and epidemeological transitions. Is there a basic intervention (or set of interventions) most needed in the lowest of the low-income group (such as Niger, Chad, Guinea), and other child-health investments more marginally effective for the middle-low and upper-low income categories?
Nils Daulaire: Firstly, the Global Health Council defines “low income” as people living on less than $2 per day (roughly 2.5 billion people). These are the people at highest risk of child mortality and morbidity, and they are our stated priority. Clearly those living at the lowest end of this scale will benefit most from the broad and proven cost-effective approaches to the most common childhood killers— childhood immunization, oral rehydration therapy for diarrhea, case management of pneumonia and malaria, vitamin A supplementation, and basic nutritional education and support. However, these programs do not significantly address the 40% of childhood deaths which occur in the perinatal and neonatal period; these require stronger systems for maternal and birth care and rapid response to early signs of neonatal problems. While these approaches are still quite basic, they require a level of infrastructure and health systems capability that may be more readily applied in middle-low income and higher settings.

Jane Roberts: In the long term, isn’t comprehensive reproductive health care and access to family planning the best long term solution? After all 40% of those 10 million deaths happen in the first month of life which means to me that the mothers were not healthy.
Nils Daulaire: I would challenge the presumption that any single approach is the “best long term solution.” What is needed is a systemic, and systematic solution that recognizes there is a spectrum of issues that need to be addressed. That said, family planning is indeed a vitally important contributor to improving child health and reducing child mortality. We know that increased child spacing and reduction in family size has a direct and very positive impact on child health and survival, as well as on nutritional status of children and their mothers, and on the prospects for education and economic opportunity. But let’s not imagine that we can reduce by two-thirds the nearly 10 million under-five deaths through family planning and reproductive health care alone. For that, we need simple but integrated programs that also work to address the leading causes of child illness and death, delivered in the same clinics and programs that are providing RH care to the mothers.

FAKOREDE AYODEJI: SOMETIMES THE PROBLEM CAN BE TRACED TO THE POOR HEALTH CONDITION OF THE MOTHERS IN SUB-SAHARAN AFRICA.CAN IMPROVING MOTHER’S HEALTH BRING GREAT CHANGE? IF SO IN WHICH WAY?
Nils Daulaire: Without a doubt, a critical determinant of the health of children is the underlying health of their mothers. If they are well nourished and have the opportunity to space and limit their pregnancies according to their own family needs and wishes, their children will have a higher likelihood of surviving and growing up healthy. However, materhal health alone will not resolve the enormous burden of childhood disease. Malaria-carrying mosquitoes will continue, whatever maternal health status. Poor sanitation will continue to make diarrhea a major killer. The area where maternal health care has the greatest potential to impact the health of children is in care of HIV-positive mothers, not only to prevent the transmission of HIV to their newborns, but also to assure the health and survival of the mothers upon whom these children depend for their own survival.

Raina Phillips: What would be your advice to a resident physician interested in making an impact on global health?
Nils Daulaire: Join the Global Health Council, come to the annual international conference on global health in Washington, DC in the end of May, meet with as many health practitioners and implementers there as you can, work toward an opportunity to serve the poor in low-income countries so that you can gain a first-hand experience that goes beyond first impressions, and THEN figure out where you might be able to provide a critical input—either in direct service, in critical areas of research, or in support for advocacy efforts to direct attention and resources to the critical health needs of the world’s poorest citizens. You can find more at www.globalhealth.org.

Victoria Sekitoleko: The communiies beligered with Poverty encourage very early marriages, say as soon as the girl is thirteen years of age, when she cannot even look after herself, she gets a kid to be fully responsible for! Is it any wonder that the babies die?
Nils Daulaire: Of course you are correct. Child marriage is bad for the girl, bad for the children she has before she is fully ready to be a mother, and bad for societies. It is a widely practiced and sadly accepted form of extreme child abuse and should be fought by legal means and changes in cultural norms. This shows that the answer to issues of child health are about more than just medical interventions. We must also look at, and respond to, the social determinants. However, all children, even those of mothers who are themselves children, benefit from essential child health services, and we should not wait for society to make the changes that are needed before we respond to the very immediate health needs of the children.

Md. nuruzzaman Haque: Dear Dr. Daulaire, I am a citizen of Bangladesh and a student of Demography in China. I would like to ask you should we focus more on infant health than child health in low income countries?
Nils Daulaire: It depends very much on the patterns of child death. In very low income societies, a considerable proportion of all child deaths—sometimes as much as one half—takes place in children between the ages of 12 and 59 months. In these situations, addressing the leading causes of death among these somewhat older children is often the quickest and easiest way to begin to lower childhood mortality. You can find more information on our website at www.globalhealth.org/childhealth. As a rule, death rates decrease dramatically above the age of 5, so older children are not a major focus of efforts. However, in most instances, it is children less than a year of age (infants) who suffer the largest proportion of child deaths, and in those instances it is appropriate to focus on their needs and health determinants. As noted in another question, addressing the health needs and survival of neonates is the largest piece of the “unfinished agenda” of child health, and should be addressed when the fundamental and inexpensive interventions addressing immunizable and readily treatable diseases are on the way to being handled.

Agnes M. Kotoh: Since most of the child health problems are in developing countries and among the poor, how can we use subsidises and exemption to ensure children from poor families have access to healthcare?
Nils Daulaire: I’m afraid you are asking a question best answered by a health economist; I am just a doctor. Clearly, we need ways to finance essential health services for poor children, who cannot themselves pay for anything, and whose families are often unable to pay for services. My personal view is that a package of essential child health services should be made universally available at no cost to those in need. That way we avoid market barriers as determinants of unnecessary illnesses and deaths, and ultimately this contributes to healthier, more productive, and ultimately more affluent societies. However, since many of these societies are very poor, this is why external support is critical to move past this conundrum, and the reason that the Global Health Council has called for affluent countries to invest an additional $7 billion a year (with $2 billion of that from the U.S) in maternal and child health programs in the world’s poorest countries (see our analysis at http://www.globalhealth.org/child_health/needs_costs/).

Amouh: Why [do] we keep on talking about the same problem over the years and we are not seeing improvment; and why are we doing it the same way?
Nils Daulaire: 1. We are seeing improvement. If we had not had child health and survival programs that started in the 1980s, we would today be experiencing more than 16 million child deaths a year. For the first time IN HISTORY this year, child deaths fell below the 10 million mark. That is insufficient progress, given that we have the tools to reduce child deaths by another 2/3 with thoughtful but very limited investments, but it is progress. 2. We are not doing it the same way. As an example, 20 years ago nobody knew about the value of Vitamin A supplementation, which could reduce child deaths by a million a year of more. Today, vitamin A programs are widely accepted and promoted. 15 years ago, few countries knew what to do about the leading cause of child deaths, pneumonia. Today, a growing number of countries have initiated effective and low-cost programs for case management with first line antibiotics. Ten years ago, more than a million children were dying each year because they did not have access to measles immunization. Today, that death toll is under 400 thousand. This is a progressive process, not an overnight miracle, but we are on the right path. What is needed now are the resources and the commitment to get the job done, which is why support for maternal and child health programs are the top priority of the Global Health Council.

Upendra: Developing contries like Nepal have high child mortality along with chronic health problems associated with low income [and] confilct. How can we deccrease child mortality in such country?
Nils Daulaire: I spent five years working on issues of child health in Nepal during the 1980s. I am gratified to know that the programs started in that period — vitamin A supplementation, case management of childhood pneumonia, maternal and child health services provided through a network of female community health volunteers—have dramatically decreased childhood mortality in Nepal over the past 2 decades despite the political turmoil that has taken place there. Nepal is definitely on the right path, and has a record of which it should be proud in the international arena. That’s not to say that there isn’t much more that could and should be done, but you should recognize that Nepal is a model for many other countries struggling to address the same problems.

Angela Albright: My observations from spending several months in East Africa is that child health (and all others) problems are heavily impacted by a lack of qualified professionals, especially nurses. Sadly, the nursing students are bright and motivated but do not have textbooks, adequate internet access, qualified teachers, and other “basics” of nursing education that are sorely needed. Most of the funding sources I saw are focused on training lowest level community workers to address a particular disease or health problem. What is the value of directing resources toward least trained community workers rather than toward a solid, sustainable education for nurses at a higher level who in turn will be able to build a healthcare system that could address child health in the context of comprehensive health programs.
Nils Daulaire: I do not believe the answer lies “just” in training community workers, nor in “just” training nurses. In order to address the health needs of children living in the poorest communities, a thoughtful and thorough analysis is needed, country-by-country, into what the principal health needs are, where people go for their care and counsel, whether nurses or community workers are more likely to be where they are needed when they are needed, and what the essential skill sets are to have an impact on health status. In other words, we need to approach this as a system, rather than as discrete and unconnected parts. Certainly, we need more well-trained, well-supervised, well-supplied and well-supported nurses—but in communities and clinics where the people are, not principally in capital city hospitals. We also need more well-trained, well-supervised, well-supplied and will-supported community workers, since they are often the first line of care and engagement, but not rank amateurs with no effective skills. I think the programs that will succeed will look at all the levels in the healthcare system, where the barriers to care and effective action lie, and what mix of health workers will best and most cost-effectively serve those needs. Even the occasional doctor may have some value.

Léon: Does IMCI (Integrated Management of Childhood Illness) really reduce child morbidity and mortality in developing countries?
Nils Daulaire: IMCI has been shown to work in clinical settings. It is based on a substantive and conceptual base that is very solid in terms of research into the individual components of IMCI. However, while it has been shown to be effective at the individual care level at facilities which have received good training and supervision, the answer is not as clear as to whether this approach works to have a significant impact on morbidity and mortality on a larger scale nationwide. I believe this will need to be tailored to individual national, and sub-national, realities (both the disease epidemiology, and the realities of health care workers and facilities) in order to get its optimal impact. One formula rarely works universally, so I would advise that you look at the situation you are in, and make appropriate adjustments that takes your own realities, as well as the scientific evidence, into account.

Chuck Woolery: Achieving, even exceeding, the Millennium Development Goals for maternal and child health is doable IF the political will exists. What will the Global Health Council do to ensure that sufficient political will is generated prior to 2015—to ensure we don’t repeat the failure of meeting similar goals established at the 1990 World Summit for Children for the year 2000?
Nils Daulaire: We have prioritized our advocacy efforts on maternal and child health, in other words MDG’s 4 and 5. This past year, the Global Health Council advocacy efforts succeeded in getting the US Congress to increase appropriations for MCH by nearly $100 million, the first increase in nearly 15 years. This is just a down payment, and we have established a goal of an additional $7 billion for this purpose from all international sources, with $2 billion of that from the U.S. We have worked actively to increase the levels of funding for PEPFAR and the Global Fund, and to support significant increases in funding for malaria and TB (MDG 6). As you know, getting money rather than words on the table is the real challenge in political advocacy, and we are working with our members (we now have Global Health Council members in over 140 countries, with over 500 organizational members who are on the front lines of services as well as advocacy) to prioritize influencing their governments, both donor and low-income, to prioritize the health needs of the poorest—e.g. MDG’s 4, 5, and 6, with a significant nod as well to the importance, neglected in the initial MDGs, of addressing reproductive health and family planning as a critical aspect of reducing global poverty. We have recently started an active dialogue with partners in Europe to establish a similar advocacy effort at the level of the EU, and have worked to strengthen indigenous advocacy efforts throughout the global South.

Michael MacHarg: Nils – thank you for sharing the time. I wondered what role you see for Ready to use therapeutic foods (RUTF) to address severe child malnutrition – especially as many advocate to bring this treatment to the community level? What obstacles do you see in implementing a broader reach for RUTFs?
Nils Daulaire: I can’t say I’m a qualified nutritionist, but based on my observations in Niger and elsewhere over the past few years, it appears that RUTF is an appropriate intervention in crisis and severe malnutrition situations. However, this does not replace the need for thorough and consistent food security and nutrition efforts that will assure two critical elements: that enough food of sufficient quality is widely available and affordable to the poorest families, and that mothers and other caretakers are educated and engaged in appropriate nutritional behaviors, ranging from early and exclusive breastfeeding, to appropriate weaning foods, to useful and valid nutritional supplementation where appropriate. I do not think that RUTFs have much of a role in addressing widescale mild to moderate undernutrition, since they will not help to build up the sustainable food production and utilization practices that are essential for long-term improvement in nutritional status. In that sense, I see RUTF as similar to essential drugs for high priority diseases.

Rahat Bari Tooheen: There are many aspects of health which do not require a lot of funds, such as raising awareness. Will raising only awareness in the developing countries improve child health? What other attributes, other than the link to mother’s health, need to be focused on?
Nils Daulaire: I disagree that raising awareness does not require funds. This is why advertisers spend billions upon billions of dollars. The critical question is: raising awareness of what, and to what end? Breastfeeding promotion is largely a matter of awareness, and has made substantial progress. Diarrhea awareness requires access to the constituents of oral rehydration solution, and appropriate education in its mixing and administration. Immunization awareness requires the presence of working vaccination programs and the infrastructure to support them. Pneumonia awareness requires the availability of trained health workers and antibiotics. Child spacing awareness requires access to safe and effective contraceptives. The point I am making is that awareness is a critical, but not a sufficient, ingredient in improving health. It needs to be a part of a larger, and well-considered health strategy, in which the healthcare system must also be an integral part.

sbyadawad@sify.com: The public is confused about pulse polio immunisation. When it would yield the proposed complete eradication [of the] polio epidemic?
Nils Daulaire: Nobody knows when polio eradication will be completed. As we have learned over the past decade, the complications of reaching the final resistant sites of polio are daunting, and are requiring far more time, resources and energy than had previously been thought. The latest reports I have seen from WHO and Rotary International indicate that significant progress is being made in northern India and Nigeria, but that transmission has not yet been broken. This requires ongoing surveillance and vigilance. If someone is giving a date for final polio eradication, they are in touch with some higher order intelligence. I believe that polio eradication in the next several years is likely, but by no means certain, and I cannot be any more definitive than that.

Satvika Chalasani: What do you think is the most important obstacle in improving child health in low-income countries? The lack of funding? The lack of basic infrastructure needed for implementing interventions? Cultural resistance? The lack of research on delivery systems?
Nils Daulaire: I believe there are a set of interrelated obstacles. First, that children and their health are truly not a political priority for many countries. Second, that resources are often not deployed for maximum impact (consider the amount of money spent on national children’s hospitals in many low-income countries compared to the money spent on first-line interventions in communities and clinics where most of the ill children are seen). Third, that effective and proven interventions are often not implemented, due to lack of analysis and information among those who set national policies as well as inadequate training and oversight of those who implement. Fourth, that the overall level of resources are still inadequate to meet the need. Fifth, that understanding and effective interventions to influence the behaviors of caretakers are often limited because of a lack of cultural understanding. There are more, but the bottom line is that child health requires a systems approach, not simply addressing one particular link in the chain, and systems thinking is often lacking among those charged with the responsibility to improve the end product: children’s health and survival.

Meghan Reppond: Given the relationship between poverty, education and nutrition, or nutrition as it relates to health, where should the intervention be made given limited development dollars, and why? Where can the intervention be most cost-effective?
Nils Daulaire: Wow, that’s a question worthy of a PhD thesis! As I have stated in response to other questions, I do not believe that there is a single “best answer” to what to do about child health. Child health and survival are the consequence of a complex set of interacting factors, several of which you have cited. Others have been cited in other questions. As a child health practitioner in low-income societies myself for many years, I came to recognize that you have to address multiple points in the causal chain, and that there is not a single formula that can pop out the “optimal solution.” This is not the same as saying nothing can be done without doing everything. In fact, I have myself participated in programs where fairly simple and straightforward interventions (vitamin A supplementation, as an example) had major and significant impact. However, those interventions are not a replacement for the reality that improved economic status, improved status of women, improved education, improved overall food security and nutrition at the household level, and improved political voice for those at the lower end of society’s ladder, all have major and lasting impacts on the health and survival of children, and of their mothers. Instead of looking for the “most cost-effective” intervention for universal application, I think we are better advised to look for what is do-able and has been proven to have impact, what meets the perceived needs of the society being served, and what is possible in the near and middle terms by the national health programs and local health efforts that are actually in place.

Birungi Beatrice: Is it possible to send me more material on children issues, like child abuse, and child development. Thank you
Nils Daulaire: Please refer to our website, http://www.globalhealth.org/childhealth/

Birungi Beatrice: Mr Nils, in most countries attention to recieve ARVS is mostly given to adults,or sometimes people with money. What do you have to say?
Nils Daulaire: Children with HIV infection have as much right to care and treatment as adults. Poor people have as much right as rich people. The focus of so many efforts over the past decade have been to focus on the RIGHT TO HEALTH, rather than on healthcare as a commercial commodity. We devote a considerable portion of our advocacy efforts to the issue of health equity, which is central to our view of a just and healthy world.

ABIOU Ulrich: Why [is it that], despite the progress of science today, too many people in underdeveloped countries haven’t information on the best way to threat their children suffering from Diarrhoeal Disease?
Nils Daulaire: I believe this is because we, as health professionals and health educators, have not fulfilled our full responsibilities. It is not sufficient to have the answer yourself if you have not effectively transmitted that answer to those who need it, in a form and manner that they can use. It is the responsibility of every healthcare worker, every government and NGO health official, and in fact every political leader, to make sure that accurate, usable information is shared with those who need it most. We should be judged on the basis of what results—in other words, on the basis of decreased cases and deaths of diarrhoeal disease—rather than on what we have said, or what we have tried. If we were all held to that standard, it would be likely that our efforts would become more effective.

Professor Miriam Labbok, MD, MPH: Dear Nils: Given the Lancet series showing that exclusive breastfeeding is the number one intervention to save children’s lives, the Horta meta-analysis on long-term benefits and the Ip meta-analysis on breastfeeding in the developed countries, and given the solid evidence reivewed at Innocenti + 15 on the need for a comprehensive program response if we wish to see sustainable impact, and givent that the ACSD and Ending Hunger approaches of UNICEF offer only that we should educate on breastfeeding, an approach that is known to have a limited impact, what can be done to increase the global funding for a comprehensive approach, including health professionals and systems, community mobilization, maternity protection and national oversight for this vital area?
Nils Daulaire: I know that you are one of the world’s experts in this arena, and I would look to you, as a longstanding member and enthusiastic supporter of the Global Health Council’s mission, to help guide us in this arena. We have made early and exclusive breastfeeding an important aspect of our advocacy efforts, and would be delighted to work with you to figure out effective ways to make this “stick” in operational terms. Let’s discuss in follow-up.

Ye Mon Myint: Why isn’t family planning been considered as one of the child health interventions?
Nils Daulaire: It is, and should always be. Please see my to Jane (above). Child spacing and family planning are a critical element of reducing child mortality, undernutrition, and chronic illness.

Dr. Papiya Mazumdar: Dear Dr. Daulaire, the recent round of National Family Health Survey (NFHS-3) in India showed high level of malnutrition and anemia among mothers and children, in-spite of the nationwide programme implemented since 1997.What you suggest should be an immediate focus for India and what ways could proved to be more effective?
Nils Daulaire: I can’t claim meaningful personal knowledge of the situation in India, but I do know that malnutrition has been a persistent problem among the poor, particularly children and mothers. I also know that efforts are now underway to revitalize primary health care services, and would hope that they prioritize basic nutrition and health interventions. Clearly the potential for immediate impact from certain targeted supplements (vitamin A, zinc, iron folate) are important elements, but need to be part of a larger and more comprehensive package that include basic immunization and acute care, family planning, and nutrition education.

Kate Tallant: What is the role of advocacy in reducing childhood death and illness caused by diarrheal disease? What are the political and practical barriers to creating an advocacy strategy that will increase global resources and support for strategies aimed to reduce diarrheal disease?
Nils Daulaire: Advocacy has two important roles, which play out in very different parts of the system. One is advocacy for resources and attention to diarrheal disease. The other is advocacy among those whose children are at risk of diarrheal death. The barriers to an effective advocacy strategy to increase resources, attention and support are, to a considerable extent, based on the MISperception among policymakers and the public that diarrhea is not a major problem. In focus group work we have done at the Global Health Council, people routinely believe that AIDS is a far greater health threat to children living in poverty than diarrhea. As you are well aware, the opposite is in fact the case. But because diarrhea does not have the same kind of political activists and celebrity support as AIDS (I once called for a celebrity spokesperson for diarrhea—guess how well that went over?), it has not entered the public consciousness in the same way. We have a lot of work to do, and I hope those reading this Q&A have ideas that they would be willing to share with the ongoing policy and advocacy efforts of the Global Health Council. The barriers to effective advocacy among those who most need to learn about and use oral rehydration therapy, and improved sanitation practices, have more to do with inappropriate or misguided health education efforts. I recall when I was working on ORS in Nepal in the 80s, we proposed that since mothers were more comfortable giving their children ORS in containers smaller than one liter, consideration should be given to a campaign to promote 1/2 liter packets and mixing cups, which we had tested and found appropriate to mothers