Global Trends In Child Health
Addressing this impressive audience of key caretakers of children will be my first
official act of office outside the Geneva Headquarters of WHO.
To me this is indicative.
Indicative of the fundamental place that children should have in our combined efforts
to improve the health of communities and populations.
Indicative of the need for WHO to reach out to others and meet that challenge in
partnership. That includes the whole of the medical profession - and especially those
who are in the frontline in the combat to secure children a safe start in life.
Paediatricians are more than just doctors prescribing treatments. You are the people we
turn to and trust for advice on the healthy growth and development of our children. This
trust makes you a very special kind of community leader. You are a powerful voice for
children who have very little voice in far too many countries.
Children are key when pursuing a future of equity and social justice. Mothers are key
to the lives of their children and to the building of healthy families and populations.
The most sustainable investment we can make in healthy populations is to take proper care
of our children's health. That investment - be it in terms of proper primary care
facilities, access to vaccines and treatment - or simply access to care - will
continue to yield throughout life.
We should have a winning case - you as paediatricians - and we as the World
Health Organization inviting partners to join in advocacy for the rights and needs of the
child - in giving better and more compelling advice to governments on how to
structure their health systems in a way that takes properly care of children.
I wish to focus the work of WHO on the vital role of health in development and to bring
it on to the top of the political agenda. That is where it belongs in a world of great
inequities and lost opportunities.
I believe we can achieve this. We are getting the evidence - not only to underline
that health is a basic human right and a value that all of us in this conference hall can
adhere to. But to go beyond and tell the decision makers - the Presidents, Prime
Ministers and Finance Ministers that investing in health brings tangible returns. A better
workforce. More receptive pupils and students able to harness the ultimate resource of the
21st century; the human resource and knowledge base. Less social costs. Less mental
stress. More human progress.
The evidence is there. It is up to us to make it available - and I have made the
creation of a special unit on Evidence for health policy an immediate priority of the new
Today I will focus on some of the global trends in child health and I will share with
you some of our thinking on how we can address them together. I stress together because I
believe it is critically important to unite the forces for health. Each of us can do very
That goes for WHO as well. WHO is a small Organization if you measure it against its
mandate - and the scores of unmet needs. WHO is not the prime deliverer of health
services. National and regional authorities are. NGOs and communities are. You are. So it
is our combined and concerted efforts that can make a difference.
The health challenges of the world are in transition. In 1990 almost half of the global
burden of disease was due to communicable diseases, problems of maternal health and
malnutrition. In 2020 it is expected that these conditions will account for less than
one-quarter of human ill-health. Non-communicable diseases and injuries will have gained
in relative importance.
That is the overall picture. But for the world's children the changes will be much less
dramatic. If we do not act now, the pattern in 2020 may well be very similar to that in
1990 - dominated by diseases of under-development - particularly among those
living in poverty - the persistence of infectious disease and malnutrition -
unsafe motherhood and lack of care.
Children are vulnerable. More than half of deaths due to acute respiratory infections
and 80 to 90 per cent of deaths from diarrhoea, malaria and measles occur among
children under the age of five.
Underpinning all of this is the vicious circle of poverty and ill-health. Poverty leads
to ill-health and ill-health breeds poverty. The poor of this world are five times more
likely to die before the age of five.
We cannot treat health as a vertical part of human development. It is an overriding and
integrated dimension. We will not be able to move decisively away from the burden of
infectious diseases if we don't manage to help populations out of poverty.
Some years ago the world discovered the critical role of education in development. Time
has come to apply the same perspective to health. Children may get enough calories but
they may not have received the critical vitamins, minerals or proteins to develop the
brains so that they may benefit from education and training. Whole societies suffer -
economies don't develop - and under-development takes its hold.
Today - as in the past - infections and malnutrition join in a lethal alliance.
Globally malnutrition underlies more than one-third of all childhood deaths.
There has been progress, but the disparities are great. In some African countries one
child in five dies before reaching the age of five. Throughout the developing world child
mortality remains unacceptably high.
Malnutrition is still haunting children in many corners of the world. Lack of food is
not the only - not even the main - cause of malnutrition. Poor feeding practices and
infections or a combination of the two are major factors.
It is as always a question of resources. But also of good advice. Targeted information
and effective advocacy is needed to guide mothers and families.
In this regard the importance of breast-feeding remains critical. Exclusive
breast-feeding should become the norm for the first four to six months of life. During the
transition to a broader diet, breast-feeding should be protected and supported up to two
years of age and even beyond.
We need to remind mothers that breast-feeding remains the most powerful prevention
against both malnutrition and infectious diseases. This is a critical message.
We also need to remain vigilantly on guard against aggressive marketing of breast-milk
substitutes that undermine breast-feeding. We need to stay on this message, even in a
situation of increasing complexities. We now have evidence on mother to child transmission
of HIV. In such situations we need to give correct and cautious advice. It is of
overriding importance to avoid a situation where mothers are generally scared from
breast-feeding. Decades of work could be lost and children will suffer.
The world may well continue to see striking imbalances towards 2020 - but it need not
be the case and it definitively cannot be our perspective. We have to look for every
opportunity to support change. Seven out of ten childhood deaths are still caused by
easily preventable or treatable diseases that have largely disappeared as major threats in
the developed world such as acute respiratory infections, diarrhoea, measles, malaria and
What can we do to trigger change and successful combat against the major health
problems of children?
First of all - in a large number of cases - we have effective and inexpensive vaccines
- one of the most cost-effective interventions available.
Talking to industry on the future of vaccines we start to hear fascinating stories.
Technological advances open new avenues that we could not dream of only a few years ago.
We may head towards effective vaccines against HIV. We may be able to prevent malaria. Not
for tomorrow but in a future within our grasp.
Again we will need partnerships - new partnerships. I believe we should have closer
working relations between WHO and industry. We have different roles - but in fact we are
all parts of the broader public health circle. Industry must push for new drugs, new
vaccines and new interventions and we must push for funding and a distributive system that
can make the advances available to all - especially to those in greatest need.
We must build on the successes of previous experiences and push our vaccination efforts
further. Even in countries with sustained high coverage rates, reaching the uncovered
populations is a considerable challenge. Vaccine costs are rising at the same time as
developing countries are expected to become self-sufficient. They may miss the train and
the costs in suffering and missed opportunities could escalate.
WHO will be an active part in a new and broad initiative to forward vaccination - with
industry, with UNICEF, with the World Bank and other stakeholders who share our vision of
health for all.
Some challenges are pressing. Of all the childhood diseases preventable by currently
available vaccines, measles takes the highest toll in deaths, nearly one million each
year. That is one million too many. 80 per cent of children are protected by immunisation
against measles, but there is still an extra mile to go.
There have been spectacular success stories, such as in the combat against polio. This
disease has been eliminated from the Americas, Western Pacific and Europe and is pushed on
the retreat in most of the rest of the world.
But again, we are not quite there. in 2010 we should be able to look back at the year
2000 and say that we reached the goal of eradicating polio. But we may also fail. We are
now learning that the eradication campaign may be running critically short of funding.
That is not acceptable. This is a combat we simply cannot afford to lose on the last
stretch. It is estimated that 600 million dollars will be needed until the end of the year
2000. Donors have to go the extra mile with us and rid the world of polio and its tragic
toll on death and disability.
Beyond vaccines there is care and cure. Families must have access to effective case
management and preventive measures. We have to think broadly - not disease by disease. WHO
has developed a successful strategy that brings together most of the essential curative
and preventive interventions needed to address the major killers of children.
The Integrated Management of Childhood Illness ensures effective combined treatment of
the five major childhood illnesses. It speeds referral of seriously ill children and it
empowers parents to care for their sick children at home, whenever possible. WHO will
share in more detail this strategy with you at tomorrow's symposium.
These are simple, affordable and yet high quality interventions. They avoid the
duplication of efforts that may occur in a series of disease-specific programmes. We need
to learn from this approach - seeing to it that what we do strengthens the health system
as a whole.
This will also inspire our approach to a new and intensified struggle against malaria.
I have pledged to the World Health Assembly that WHO will take the lead in Rolling Back
Malaria. We cannot at this stage opt for eradication. But we need to act. For some time we
thought malaria was declining. But it is bouncing back taking heavy tolls, especially in
Africa but also in Asia and the Americas, and especially among the most vulnerable.
That means among children. Every day up to 3000 children die from malaria. Every year
there are up to 500 million cases among children and adults.
Many of those who are infected but do not die get their lives destroyed. The suffering
is daunting. The economic consequences are striking. Malaria is one of the biggest killers
in sub-Saharan Africa.
Africa is responding to the threat. We must hear Africa's call. Roll Back Malaria is a
broad global partnership aimed at significantly reducing mortality from malaria. WHO
cannot do it alone. We are building a coalition bringing with us the World Bank, UNDP and
other UN agencies. And most importantly - we are placing the countries concerned at the
core of the coalition.
Our efforts aim at combating malaria through a strengthening of the local health
systems, enabling them to bring relief and assistance to the prime caretaker - the family
and especially the mother. And we must push ahead in the technological field.
What we do in Roll Back Malaria will have an impact beyond malaria control. What we
learn in terms of strengthening health systems and bringing relief to the vulnerable will
benefit our struggle against HIV/AIDS and a future Roll Back Tuberculosis.
I invite donor partners to grasp this opportunity and support our efforts to roll back
the biggest child killer in so many African countries. The G7 countries have declared
their readiness to lend their support. It is now time to move ahead.
Roll Back Malaria will have a special focus on children as the most vulnerable and the
mother as the prime caretaker.
Mother and child is a vital connection. We know the critical role of young women in our
quest for development. The vulnerable girl child - the young woman - the young mother -
the grandmother - the prime caretakers.
The health of women and the health of children are inextricably linked. The improvement
of women's health, including their reproductive health, is critical to the improvement of
child health. This must start in childhood and include attention to the needs of
But let us not forget the man - the vulnerable young boy - the young man - the
responsibility of the father and the grandfather. Safe motherhood - yes. But also
responsible fatherhood. We need a new cultural focus; on the shared responsibility - on
the roles of both women and men - and ultimately of the family.
Over the last decades there have been global improvements in childhood and infant
mortality rates. But there is a critical exception. Foetal death and death in early
infancy have proven resistant to health interventions.
In Africa 75 per 1000 live born children die before reaching one month of age. In the
developing world one-sixth of all children are born underweight. This is really a
mother-issue. There is no way to deal with this major problem if we do not look beyond the
child and recognise that health services for women including reproductive health services
must be improved.
Let us move to the HIV/AIDS pandemic. You know the challenge facing us. If parts of the
developed world may claim they are controlling the disease, the opposite is the case for
large parts of the developing world.
The predictions seem clear: HIV/AIDS will claim a greater share of child mortality in
the years ahead, partly reversing the gains in child survival that have been achieved with
such difficulty, also upsetting other social and economic hardwon gains.
More than a million children under 15 are living with HIV, while more than two million
have already died of AIDS. Africa has the highest proportion of childhood HIV/AIDS cases.
But the incidence rates are rising with alarming speed also in Asia.
Adding to this terrible burden upon families and societies we must include the
thousands and thousands of children orphaned by AIDS. Many of these children will already
have died as a consequence. Those who escape the consequences of HIV/AIDS in childhood
grow up to face the risks of infections as adolescents. Health education related to
HIV/AIDS must start early enough in life to be effective when sexual activity starts.
WHO has just taken over as chair of the cosponsors of UNAIDS. We will lend our full
support to the efforts of UNAIDS and give increased attention to the way WHO addresses
HIV/AIDS in all parts of its work.
The perspectives are daunting. But we must not stop pushing ahead. Among the setbacks
there are stories of hope - there are better policies to pursue - for governments and for
health systems. Together we must make the best advice available and strive for new
technological insights and see to it that the advances are made available to the many.
Let me then shift the perspective to the global change in the burden of disease.
Urbanisation and changing lifestyles are quickly changing the picture of public health
challenges. In 1960, 35 per cent of the world's population were urban dwellers; in the
year 2000 this will have risen to almost 50 per cent and there are expected to be 24
cities in the world with a population of 10 million or more.
Often urban life means unsatisfactory living conditions and unemployment. This is also
a vicious circle, resulting in increased stress and higher incidence of psychosocial
We need to focus on these challenges. The health systems of many countries are not
prepared to face this new tide of non-communicable diseases, in itself an epidemic.
Our knowledge is not sufficiently developed. That is why I have wanted WHO to take this
seriously from the outset. We have created a special focus on the health challenges
arising from social change and mental health. We are broadening our environmental work to
encompass the inter-linkages of sustainable development, the effects of world trade and
the globalisation of the world economy.
We need to better understand the broader health consequences of a changing world, we
need to advance our research and we need to come up with more timely advice on the best
practices and policies.
One example may illustrate this: We now have increasing knowledge to say that injury is
becoming a major health problem - for all age groups - but especially for
Injury accounts for more than 10 per cent of the burden of disease in children under 15
years of age. Injury is often due to falls, fires and miscellaneous accidents of the local
environment, and a very significant proportion is due to road traffic accidents.
We need better knowledge and we expect that the Global Programme on Evidence for Health
Policy will bring us a better understanding of the facts and the trends, thus enabling us
to put forward more accurate advice.
From the outset we are paying special attention to tobacco and smoking, with an initial
focus on the protection of children.
Why take this difficult struggle? I invite you to consider the evidence. Today more
than 3 million people die from tobacco every year - half of them dying in middle age, not
old age. In 2020 that number is likely to grow closer to 10 million with the bulk of the
growth coming in the developing countries. That will make tobacco the single largest
contributor to the global burden of disease.
It is already a shocking reality that up to 300 million of today's children will
eventually die of smoking-related disease if current trends continue. By 2020 as much as
16% of the total disease burden in China may be due to tobacco.
The World Health Organization cannot shy away from these facts. As a doctor I am
obliged to say: Tobacco is a killer. Smoking should not be advertised, subsidised or
We are engaging in a broad alliance with other UN agencies - such as UNICEF and
the World Bank - with NGOs and a number of stakeholders to drive home that message,
especially to support countries who are not prepared to face the tide that may be coming.
Children have the right to be protected. They are the most vulnerable. We expect
governments to protect children against health threats from traffic, injuries and
violence. Then we must also take tobacco seriously.
Most adult smokers started smoking before the age of 18. The industry knows it and acts
accordingly in their marketing strategies. If tobacco-related disease is to be curbed
children should grow up in a world where homes, schools and working places are tobacco
free. Warnings on cigarette packets are not enough. We need a far more decisive approach.
Interventions to reduce smoking do work. Twenty years ago nearly 50 per cent of
Canadians between 15 and 19 smoked. That figure is now under 30 per cent, still too high
but pointing in the right direction.
As paediatricians you know it: putting children first is a sound public health
approach. If we evaluate our living conditions from the perspective of the child's lungs,
heart and brain a lot may look different.
Solutions to many major child health problems are to be found in better housing,
reduced air pollution, improved water supply and sanitation.
Let me share with you one observation: Next to the burden attributable to poor water
supplies, poor sanitation and poor personal hygiene, the largest environmental risk factor
is respirable particles. This includes human exposure to respirable particles indoors and
More than 90 per cent of the global human exposure to respirable particles is indoors
rather than outdoors. Indoor air pollution may kill more than 1 million children a year.
We need to carefully assess the magnitude of this threat to child health and develop
strategies to reduce this unnecessary hazard.
If the trends documented in the first part of this decade continue, the population
without an adequate water supply will decrease globally but will continue to increase in
Africa. For sanitation, the situation is worse. Unless improvements are accelerated, the
under-served population will actually increase in all regions of the world. And children
are the first to suffer.
At important UN conferences over the past few years the countries of the world have
made pledges and promises to allocate more resources next year than they did this year to
health, education, reproductive health and the struggle against diseases. They have
promised to make men and women equal, to rectify disparities and to promote women's needs
more actively than men's until we can safely say that equality is reached. This is what
the Cairo conference was about. This is what Beijing was about.
Children have rights - rights to health and health care. One hundred and ninety
one countries have ratified the Convention on the Rights of the Child.
In its article 24 the Convention calls on states to implement measures to diminish
infant and child mortality, to ensure medical assistance and health care to all children,
to combat disease and malnutrition and to ensure that parents and children have access to
education and are supported in the use of basic knowledge of child health and nutrition,
the advantages of breast-feeding, hygiene and environmental sanitation, and the prevention
This may well serve as a blueprint. UNICEF is making a renewed call on member states to
live up to their commitments. It is a timely reminder that WHO fully supports.
Looking ahead we should continue to put children first. The wealth of a nation could be
judged by the wealth of its poorest members. Likewise, the health of the world should be
judged by the health of its most vulnerable population. That means children, and
especially children of the developing world.
The opportunity that faces every little child is fundamentally unequal. The destitute
poor have for too long been kept at arms length by good wishes and the rest in promissory
notes. As Martin Luther King said - the check has come back from the bank of justice
marked "insufficient funds".
There will be a critically unfinished human agenda as long as children are born in
utmost poverty. As long as children open their eyes only to die of curable causes. As long
as there are drugs and vaccines available - but not available for all. As long as
children die or suffer because their families lack basic knowledge.
Ten years of experience as a physician - many of them devoted to children -
and 20 years as a politician have taught me that improved life conditions for all - a
greater range of choice for all - access to information and essential health and
social services are the sources of human progress.
That is the conviction that I bring with me to WHO and it will guide me in my
dedication to help making a difference in the quest for better world health.
And in that quest I know that you who are in the frontline in the struggle for child
health will be on our side. I invite you to join us and be advocates for the broader child
health agenda. Focusing on child health. But also bringing in the broader perspective of
development, equity and the need to forward policies of redistribution.