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Call for global child development initiative

Closing remarks by William Foege* at the World Bank Conference on Investing in Our Children's Future, 11 April 2000

Introduction

First, our thanks to Mary Young (World Bank Early Child Development thematic group leader) for assembling the people who have attended this conference. For many, they are here only because of her and it is a tribute to her that this step has been taken.

We have experienced a wonderful meeting that has included:

• An interpretation of the science
• A celebration of creativity
• By Raffi
• In the exhibits
• In the presentations
• An understanding of the role of health in development
• The importance of early childhood investment in both
• A balanced view of development. As Kul Gautam (UNICEF Deputy Executive Director) pointed out yesterday, when it comes to understanding the value of investment in children, we may have done our own structural adjustment in recent years
• The need to make explicit, the link between the needs of the poor and the fears of politicians. Politicians fear losing office and we need to ask, "What are the political benefits to supporting child development?"
• The plea to develop ways of measuring and evaluating. We know from other programmes that you get what you inspect, not what you expect.
• The challenge of sustainability. One way to get sustainability is to change social norms. There was a time when measles was an expected childhood disease. Now a single case makes the news and calls into question what the health department has done.

On 9 May 1999, The New York Times included a message taken from a subway booth. "Lots of people confuse bad management with destiny." The purpose of this meeting is to create better destiny through better management.

Stephen Hawking, in his book, A Short History of Time, says the history of science is the gradual realization that things do not happen in an arbitrary fashion. This is a cause and effect world.

This refreshing meeting did not occur in an arbitrary fashion. The organizers are not fatalists. Those here assembled are not fatalists. We think there are ways to decipher the science and invest in a better future for every child, in every country.

We start with the premise that...

This is a cause and effect world

Even when we don’t understand either the causes or the effects. We study history because it convinces us that every thing that now exists has a history. Therefore everything we now do will have ripples into the future. It makes a difference what we decide to do. We would not be here if we didn’t believe that...

President Wolfensohn started yesterday with the importance of the early years. And we heard about windows of opportunity. Of course the brain is dynamic and plastic...for some things.

It is never too late for some things we...can improve our knowledge, continue our interests, and continue giving to others, even when terminally ill. We can improve some things until the very end.

Other things can never be recouped.

Richard Feynmann, the great physicist, said that it takes very little energy to scramble an egg, but science is totally unable to reverse that simple process.

We cannot reverse the retardation caused by insufficient iodine in the first months and years...

We cannot return function to the legs of a child crippled by polio...

We can’t eliminate the past from a child traumatized by war.

And as we just heard by the panel. We are dealing with both positives and negatives. That is...deficiencies but also toxins, such as alcohol during pregnancy. Smoking...where the problem is that it is the first pack that kills you, not the last. Just as real as the lack of iodine or the presence of tobacco smoke is the absence of attention or the presence of abuse.

Two years ago, the Centers for Disease Control and Prevention (CDC) published the first scientific study on the health of adults who were abused as children. The study looked at physical, psychological, sexual abuse, the witnessing of a mother being beaten, a person in the family using drugs, or going to jail. While it won’t surprise you, this was the first time it was documented that smoking and drinking, the use of drugs, depression, suicide attempts, being overweight, were all elevated in people who had experienced such adverse events in childhood.

In 1962, C. Henry Kempe...coined the phrase "the battered child syndrome." We know there are genetic influences that influence our mental health. But we need to know the influences of our upbringing that also play a role in our mental health. The "battered child syndrome" leads to a "battered adult syndrome." And the accumulation of battered adults leads to a "battered society syndrome." And this battered society in turn fosters battered children.

We heard yesterday that a society is healthier if the range between the rich and the poor is reduced. That provides a challenge to the World Bank to figure out how to make Standard Deviations as understandable as averages.

So why are we here? Because it doesn’t just take a village to raise a child. It now takes the whole world to raise a child and we want to figure out how to do a better job.

The inefficiency of current approaches

Infant mortality -- To go through pregnancy, to feed and nurture a child for nine months, to love that child, and then to lose the child to measles is heart rending. But it is also inefficient.

If the child survives measles and continues to thrive through school, only to get AIDS in the early 20s, it is again, heart-rending and inefficient.

To raise children depressed and addicted, because of abuse as a child...is inefficient. Preventable retardation due to micronutrient deficiencies is inefficient.

And so we must be aware of the inefficiency of not providing health and educational benefits to all children. Or the inefficiency of providing prisons for people, because society saved a little money on health or education, or support, or community programs, when they were young. This is not a rational way to plan societies.

Why do such inefficiences persist?

This doesn’t happen by accident. One reason involves our very human tendency to procrastinate. We don’t focus on prevention. For example, the system puts a much higher value on treating lung cancer than in helping people to stop smoking. Despite our emphasis on children and our investment in Head Start, President Carter points out in his book, The Virtues of Aging, that for every $12 spent on people over 65 the federal government spends only a single dollar on children under 18. For all of our rhetoric on prevention and children it is not where we put our money.

It was a big step to go from disease prevention to health promotion. With disease prevention we were always focused on pathology and asking, "How could we reduce the extent of a problem, or the deaths from a pathogen." With health promotion the target changed and the philosophy changed. The object was not just to bring some adverse event down to zero. The object became how to change the scale and go to a positive perspective.

That is one thing that has been missing in our thinking about children. We have taken a pathological approach…which means we wait until the disease is evident before we react. We desperately need leadership decisions that ask, what is good for the future, what is good for the entire world. Where you realize that the vast majority of the public that you serve has not yet been born and is not of your nationality.

There are two barriers to good decision making in global health. The distance between the decision and the effect…the greater the distance the more difficult it is to make good directions. And the time between the decision and the effect. The greater the time, the harder it is to make good decisions.

The most difficult is to make a decision that involves both. That is why it is so difficult to make wise decisions involving nuclear or toxic wastes with an incubation of hundreds of years and disposal in other countries. That is why it is so difficult to invest in positive child development, where the results will accumulate over generations, and then centuries.

What could we do?

It means not being a fatalist. Believing we can change society, and the future and our own health destiny. It means determining what can be changed and what can’t.

Today there are a half dozen people attending the meeting from the Collaborative Center for Child Well-being. The Center is taking the approach that the best decisions on investing in child development will be made if decision makers have access to the best science.

The Center is doing two things.

First, it is defining the positive core elements associated with successful living. They include:

• Physical health and fitness
• The ability to trust and cooperate
• The ability to form good relationships
• Problem solving abilities
• Empathy
• Goal persistence
• A feeling of social responsibility
• Purpose in life

Second, the Center is organizing the information on fostering these elements into a three dimensional matrix, to better understand relationships and to determine how best to intervene.

One axis looks at stages of life from preconception to old age...and asks what could influence those core elements at every stage.

The second axis looks at four domains:

• Physical
• Cognitive
• Emotional
• Social

The third axis looks at the environment...from the most intimate relationship with parents, to family, community, state, nation and the world.

The science is being evaluated by looking at the quality of individual studies and then characterizing the strength of the body of evidence.

Two messages from this effort. First, the scientific understanding is improving rapidly. This will fine-tune decisions and we need to continue investing in the science. But second, we don’t need more information to act immediately.

We already know that it makes logical sense to protect children from malnutrition, unnecessary illness, social upheaval, war and instability.

We already know the value of educating all children.

We already know the value of supporting parents to interact with their children, to communicate, to tell stories, to read to them if literate, to invest in them especially during the early years.

We heard that some argue against the importance of the first three years and yet the conclusion was found in the comment of Rob Reiner that, "Those first three years last the entire lifetime."

Just as we teach that financial security in retirement is enhanced by a savings program at an early age...so should we view the world’s future security as dependent on our investment today. Ethnic conflict is not genetic. It is all learned. We could change that. Don’t confuse bad management with destiny. We could make the future more stable and less violent.

Kul made the point yesterday that our investments are far reaching. We must constantly raise the question of what is the best decision for 500 years from now.

In 1806, Thomas Jefferson wrote a letter to Edward Jenner to thank him for the development of smallpox vaccine. He said, "Future generations will know by history only that this loathsome disease has existed." He saw the future 170 years before it occurred.

Future generations will know and be grateful that in the year 2000, the politicians, the economists, the scientists of the world finally invested adequately in their children.

We simply don’t need more information to know that conflict in Africa, in the future, is less likely if we take conscious steps right now, to help 11 million AIDS orphans.

Some of you are familiar with the concept of the "tipping point." It tells us that...

• There is a drop that causes the glass to finally overflow.
• There is a moment when a friendship becomes permanent.
• There is a minute when a vaccine provides protection.
• There is a day when the world finally does right by its children.

What do we need to do? If children are to have the positive core elements that offer them a successful life, that is more likely to happen if they have parents with:

• Nurturing Capacity
• Good Mental Health
• A network of Positive Social Support

And that is more likely to occur in a:

• Society committed to parenthood
• Society committed to equity
• Society with an adequate education system
• Society with an adequate child care
• Society with economic stability

I left this meeting for a few hours today to testify before a US Senate hearing on global investments in childhood immunizations. Fifteen years ago, the single most lethal agent in the world was the measles virus. It killed three million children a year. That toll has been reduced by two-thirds. Smallpox has disappeared and polio will soon be gone. The power of vaccines has been demonstrated.

Now there is a remarkable coalition, fuelled by the Bill and Melinda Gates Foundation, putting one billion dollars into immunization in the next five years. This has led to UNICEF, WHO, the World Bank, industry, non-governmental organizations, medical missions groups, everyone, determined to make immunizations available.

The goal is to extend the coverage of the basic six vaccines, introduce second generation vaccines such as Hepatitis B and H. influenza B to developing countries, and to promote the development of vaccines for the poor of the world. Vaccines for AIDS, tuberculosis and malaria, for example.

The coalition combines good science with good policies, for the future of the world.

Immunizing children is easy compared to providing an environment conducive to optimal development. But immunization advocates learned that it takes a global coalition to make the program work, and so they have developed the Global Alliance for Vaccines and Immunization, including the global agencies, foundations, industry, the public and private sectors.

Likewise with child development.

• Improvements will not come by chance.
• It won’t result from inspiring meetings...as this has been.
• It won’t happen by uncoordinated projects, by rhetoric, by good intentions.

We need to deliberately plan a global coalition for child development, to capture the "tremendous political commitment" and the feeling that " we are all in this together."

If that is to happen, the World Bank is the place to make it happen. In the words of Secretary Shalala, "Build it and change will happen."

Build it through a conscious decision to combine our resources, our experiences, our new science, our ingenuity, our sense of community, our new approaches to education. Build it so that Ministers of Child Development will become the norm.

In closing, I thank Mary Young for creating this milestone. For assembling the people with diverse interests, expertise and talents. People held together by a shared objective of creating a world that honours children by enhancing their positive development.

And having thanked her, I now challenge her, to get the World Bank to take the next step. The step of assembling an Alliance similar to the Global Alliance for Vaccines and Immunization. An alliance that can promote, measure, and improve child well-being. An alliance that works to have a focus in each country, responsible for child development.

When a country deems something important, whether health, education, agriculture, finance, or trade...it holds someone responsible for furthering the country’s interests. Two provinces of Canada have provided the example.

Finally, we build on the work of many who have gone before. I mention three.

As Jim Grant, former head of UNICEF said in his last speech to the UN General Assembly, "The vital vulnerable years of childhood should be given a first call on societies concerns and capacities...There will always be something more immediate; there will never be anything more important. If we believe that, lets organize to do it. Lets combine authority, resources and responsibility in a person in every country.

Gandhi said that people often become what they believe themselves to be...and children often become what their parents and society believe them to be.

Jonas Salk said, "Evolution will be what we want it to be"...if we can envision it we can achieve it. So creating that future starts with the ability to envision it. That was the purpose of this meeting.

And so I repeat. There is a day when the investment in children passes a point of no return. All children after that day will benefit.

That day might just as well be today.

Thank you.

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