To the 12th Annual IHMEC Conference:Health challenges for children in world cities.
New York - 6 March 2003
Dr. Neusy, Dr. Rosenfield, Members of the Medical Profession, Ladies and Gentlemen:
On behalf of UNICEF, I thank Dr. Neusy and the members of the Consortium for this opportunity to address the challenge of public health in an increasingly urbanised world - and what we must do to ensure the welfare of our most precious natural resource, our children.
Carol Bellamy, UNICEF's Executive Director, asked me to convey her regrets that she could not deliver this keynote address herself. She had looked forward to being here, but has been unavoidably delayed by the press of business at a special meeting of the Global Alliance for Vaccines and Immunization (GAVI).
Mr. Chairman, the theme of this year's Conference could hardly be more timely. Nearly half of the earth's 6.3 billion people are city-dwellers - and as Dr. Neusy points out in his White Paper, the UN has estimated that in a little over 20 years, that figure will rise to over 60 per cent.
The UN Secretary-General, Kofi Annan, has called sustainable urban development one of the most pressing challenges facing the human community in the 21st Century. For while the world's cities are becoming hubs of dynamism, change and opportunity, they are also becoming platforms for exploitation, unemployment and disease.
All of this has profound implications for the survival and development of the world's children, who represent at least half of the nearly 3 billion people who live on the equivalent of $2 a day or less.
Slums - also known as peri-urban squatter settlements - are growing rapidly in the developing world, their populations swelled by rural migrants who are arriving in such numbers that most overall city populations are doubling every 10 to 15 years. They are home to some 800 million people, or nearly 40 per cent of all city residents.
The overcrowding, poor housing and lack of adequate sanitation make these areas ideal staging areas for epidemics of child killers like diarrhea, measles and acute respiratory infections.
The lack of meaningful employment and resultant poverty, especially for women, is a boon for commercial sex, which fuels the spread of sexually transmitted infections - especially HIV/AIDS.
In many urban areas, HIV/AIDS, poverty and overcrowding are fueling a resurgence of tuberculosis. Indoor air pollution from cooking fires is a danger to child health, while tobacco products - aggressively marketed in the developing world by multinational corporations - is a factor in increased rates of pneumonia in children. And this is quite apart from the rising toll that tobacco is taking on adults, many of whom begin smoking in childhood.
Slum conditions are also behind the growing worldwide population of children who lead Hobbesian lives in the streets, begging, stealing or engaging in commercial sex.
The sheer scale of all of this feeds a sense of hopelessness among impoverished urban children and their families - and because it inspires inaction, that hopelessness is the greatest challenge to addressing their plight.
But if there is just one message UNICEF can leave you with today, it is that there is hope. We can make good on the international commitment to give every child a better future - but only if that hope is translated into a vision - a vision implemented by clear planning, determination, hard work and resources, however modest.
That vision must include, first and foremost, land tenure, based on sound principles of urban planning. When poor people are given title to a piece of land, they will build better housing. This should decrease the recourse to lands prone to flooding or mudslides. Safe water - and a connection to a sewer - can then be provided on a cost-recovery basis through metering.
Access to electricity will mean better light for homework at night, better access to information through radio and TV, and less risk of burns for children.
Safe places to play in fresh air and sunlight are also important. A soccer field, a few benches, some trees and a piazza can transform a slum.
These may seem like simple measures, but we know from experience that they can have an immediate and profound impact on child health. And better child health outcomes will also result when there is access to information, education and communication about family planning.
Mr. Chairman, if we are to address the challenge of urbanisation, it is crucial that national and municipal governments, civil society and development agencies fulfil their commitment to increase the number of health centres - centres that will help the world move toward universal health coverage, using high impact, low-cost programmes like immunization, provision of Vitamin A supplements and promotion of breast-feeding.
Mr. Chairman, the groundwork for ensuring the health and well-being of children was laid in the 1980s, when UNICEF and its partners helped place health issues firmly on the world's political and social agenda, cultivating ownership by mayors and governors, parliamentarians and civil society activists, the media and the academia.
Diarrhea and a host of vaccine-preventable diseases were targeted to demonstrate that dramatic progress could be made in promoting child survival. Millions of lives were saved with the low-cost, high-impact techniques of oral rehydration therapy and childhood immunization. These interventions applied and elevated the concept of social mobilization as a powerful tool to promote health.
Inverting the motto of Health for All to ALL for Health, the child survival and development revolution saw everyone, from film stars to schoolteachers, heads of religious organizations to heads of states, actively involved in promoting ORT, immunization and other health and nutrition interventions.
Inspired by the success of the child survival revolution of the 1980s, UNICEF helped convene the World Summit for Children in 1990. This Summit, the largest gathering of world leaders until that time, adopted an ambitious agenda for further promoting child survival and development through common goals with clear time-bound targets, using relatively low-cost and high impact public health and nutrition actions.
This simple concept of focusing on time-bound results has had a profound influence on modern development thinking. Through successive major international conferences and summits of the 1990s, the international community has committed itself to a common development agenda with clear goals and targets.
This goal-oriented approach to public health and development was a powerful complement to actions required to achieve the human rights standards and principles set by the 1989 Convention on the Rights of the Child, that also came into being just before the Summit.
The Convention, which quickly became history's most universally ratified human rights treaty, codifies children's right to survival, basic education and to health care, nutrition and sanitation.
It is now widely recognised that each and every child has the right to an essential package of health interventions. Programmatically, this translates into moving as quickly as possible towards universal coverage, a fundamental public health concept.
Despite many successes, we have failed to reach numerous goals for child survival and development that were set at the World Summit for Children. As a result, nearly 11 million children under the age of 5 still die each year, most from readily preventable causes. Some 150 million children remain malnourished. Another 120 million children are still out of school, a majority of them girls.
At the same time, HIV/AIDS has grown into a catastrophic pandemic, eroding decades of gains in child survival and development in large areas of sub-Saharan Africa. In many societies, HIV/AIDS is destroying the very people and institutions that are needed if there is to be sustainable development - or any development at all. In the most affected countries, up to 25 per cent of young people are HIV-positive. Last year alone an estimated 800,000 children worldwide were infected during birth or breastfeeding - 90 per cent of them in sub-Saharan Africa.
The Summit for Children in 1990 was held as the cold war was ending, amid hopes that the vast resources squandered on military expenditures might now be available for development. Instead, in the decade since the Summit, the world has witnessed unprecedented levels of ethnic conflicts and civil wars in which children and women have become either direct targets or collateral victims.
The increasing number and intensity of conflicts in the world is severely undermining children's health and security. As Graça Machel wrote in her UN report on The Impact of Armed Conflict on Children, "conflict is a major public health hazard that cannot be ignored. Any disease that caused as much large-scale damage to children would long ago have attracted the urgent attention of public health specialists. When armed conflict kills and maims more children than soldiers, the health sector has a special obligation to speak out."
Mr. Chairman, if many goals of the World Summit for Children remain unreached, it is not because they were too ambitious, or were technically not feasible. It is largely because governments and donors failed to make a sufficient investment in basic social services.
With a few honourable exceptions, throughout the 1990s investments by developing countries and donors fell far short of the internationally agreed-upon norm - that developing countries should devote 20 percent of their national budgets to meet the most pressing needs of children in primary health care, nutrition, basic education and sanitation; and that donors should devote 20 per cent of their aid allocations.
In the larger scheme of things, the resources needed to provide for the basic needs of children are modest and affordable. With modest amounts of external support, even the poorest countries of the world would be in a position to afford basic social services. The missing ingredients are often not resources but lack of vision, unwise priorities and commitment of leadership.
It was to summon such vision, commitment and leadership for the world's children that the United Nations convened a new set of Summits in the past two years, in particular the historic Millennium Summit in 2000 and the UN General Assembly's Special Session on Children in 2002.
Like its predecessor, the World Summit for Children, the Special Session outlined a 21st Century agenda for child health and development. Titled A World Fit for Children, its bottom-line goals include reducing the infant and under-5 mortality rate by at least one-third, with an eye to cutting it by two-thirds by the year 2015; implementation of early childhood development programmes to ensure that children have a healthy start in life; and the reduction by at least a third of the proportion of households that lack safe and affordable water and sanitation.
At the Special Session, we were thrilled that leaders from all walks of life, from Nelson Mandela to Bill Gates, from religious leaders and parliamentarians to media moguls and civil society activists united in their resolve to create a global movement for children. Children and young people themselves were among the most inspiring participants, bursting with energy, creativity and commitment to build a better world for themselves and posterity.
Ladies and Gentlemen, we owe it to the children of the world and to the future of humanity to bring the benefit of our knowledge, expertise and commitment to the cause of Health for All. We who work in public health have the privilege - and the special obligation -to be in the vanguard of those promoting global public health. Human beings have the right to the highest attainable standards of health - and health is closely associated with human security, productivity, national development and international solidarity.
As public health specialists, you will need to work with partners and decision-makers far beyond hospitals, clinics or departments and ministries of health. To be truly effective you will need to mobilise support from sectors outside health.
I would also urge you, in addition to being medical practitioners and technical experts, to also be skillful brokers, negotiators, and diplomats in the pursuit of the Health for All goals - in short, builders of tomorrow's world - a world that is truly fit for children. As we ride the next wave of revolution in public health, I have no doubt that together, we will meet these expectations - and write a new chapter for better health in the 21st Century.