Editorial

Indian Pediatrics 2001; 38: 127-131  

Beyond the Millennium: What Can be Done to Improve Child Health in South Asia?

The Sydney Olympics and all the hoopla surrounding them are over, and the daily ritual of cricket, bollywood and soap operas once again bombards the residents of South Asia. One would have expected heads to roll in the aftermath of the most successful Olympics ever, yet hardly a whimper has been heard about the abysmal performance of athletes from South Asia. Few have lamented the fact that a people representing almost a fifth of the world’s population, failed to produce a single exceptional performance, and in many ways lagged far behind athletes from far less fortunate economies. For a people who have conquered the mysteries of the atom and taught the world the nuances of information technology, this failing is both mystifying and heart breaking. One may quibble whether this has anything to do with child health and that this failing may represent nothing more than the lack of a sports culture in the region.

Some of us would beg to disagree. Not only is this issue extremely pertinent to child health but also a major barometer of how much a society is willing to invest in the health and well being of its populace. It may also represent a consequence of fundamental limitations in the state of health and nutrition of its children and youth. The analogy to the rest of the living planet is startling. For every species that man has studied, tamed, conquered and cloned, it is evident that much of what can be achieved in the peak of youth and adult life has its roots firmly planted in the beginning of life and early childhood. It is not a question of "nature versus nurture", but a combination of the two. In a subcontinent where almost a third of all newborn infants have suffered prolonged malnutrition in-utero, it is difficult to imagine that the majority would eventually catch up and escape unscathed. This is especially so as after birth the frail and sickly low birth weight (LBW) infant often encounters some of the highest burdens of diarrhea and early childhood infections globally(1), compounding malnutrition. It is therefore not surprising that malnutrition rates in the region have remained virtually static(2), with pitifully small secular trends(3). What was once labelled an "Asian enigma"(4) is no longer a mystery in that we know that the high rates of malnutrition, LBW, early childhood morbidity and micronutrient deficiencies are closely intertwined with the status of women in South Asia. Thus no real solution for early childhood malnutrition and deprivation is possible without addressing the problems of maternal status in society, empowerment and health. From a public health perspective it is thus futile to consider early child health in isolation of the health of the mother.

The contrast between the advances made in maternal and child health in Sri Lanka and the other major countries of the SAARC region is stark. The three major newly independent states, namely India, Pakistan and Sri Lanka (then Ceylon), were at roughly comparable states of development a half century ago. Today Sri Lanka stands out as a beacon of hope for the rest of South Asia, epitomizing the enormous gains in health and development that can be made with limited resources. These improvements in maternal and child health were made largely by a massive investment in education and primary health care. There are many lessons to be learnt from this practical example from our own neighbourhood, of investment in education and human development and its downstream effects on health and nutrition. For too long have pediatricians and public health specialists looked for "quick fire" solutions to the overwhelming misery and disease that surrounds them. There are none and to separate health from other development issues is an error of Herculean proportions. What is needed is a program of holistic development that has human rights and gender equity at its soul.

It is particularly in the area of maternal and child health that human development and gender equity emerge as issues of fundamental importance(5). As rapid globalization imposes a market doctrine on all of us with no more than a premise of "trickle-down" economic benefits, few realize that this has rarely worked outside of societies with strong social security and support mechanisms. These safeguards hardly exist in many developing countries and there is considerable evidence from other parts of the world that the introduction of such measures and structural adjustments is associated with increasing unemployment, disparities and poverty(6-8). The sections of society that are most exposed to these trends are the most vulnerable, namely the women and children. The recent data on increasing poverty in Pakistan and its disproportionate impact on women and children is a stark illustration of this fact(9). Even where safeguards exist, the benefits of targeted child health interventions may flow disproportionately to those in lesser need, with increasing inequity(10). The impact of this so called "Matthew effect"*  has been well recognized in several developing countries(11), except in relatively egalitarian societies with strong social security systems(12), and therefore it is hardly surprising that despite a large number of vertical programs of child health and nutrition, the gains made in maternal and child health for the truly impoverished masses in South Asia are abysmal.

These disparities are particularly notable with grandiose vertical programs, which more often than not, fail to take grass root problems and realities into account. The key therefore lies in the support and promotion of indigenous, flexible, culturally sensitive and rele-vant solutions, rather than the carte blanche imposition of imported ideas. In a subcontinent where the majority of births take place in the hands of traditional birth attendants, it has taken decades and the dogged determination of an NGO to prove that it is possible for community health workers to provide domiciliary care for sick newborn infants(13). These are however, still small scale and isolated approaches, mostly within the health sector, whereas the crying need is for an integrated program of multi-disciplinary interventions incorporating several sectors. Despite isolated examples to the contrary(14), in general the best achievements have only been in areas where health sector interventions have been coupled with general social sector development, indicating that health is an integral part of development(15).

What then is the way forward? I for one, am convinced that the true solutions lie neither in the laps of the health professionals, nor in the corridors of power. They actually lie with the multitudes at the grass root level, which have become systematically inured to the status quo. The issue of maternal and child health in South Asia is one of fundamental human rights, the right to education, the right to adequate nutrition, the rights to basic health care and immunizations and fundamentally, reproductive rights. These rights once fulfilled, specifically by the creation of a demand by civic society, are key to sustaining any gains in the health and nutrition(16). Linking early child health and development with future health and economic benefits to society are thus key concepts to nurture and drive home. This is also the only way to create a combination of demand and accountability at the grass root levels, so that the failings of the health system can be identified(17). The example of Kerala is often cited in the development circles as an "outlier". Why? Because it has had a long standing track record of investment in basic education and boasts an egalitarian society! In others parts of the region, especially in Pakistan, where many a multitude still suffers at the hands of feudal masters or religious zealots, human rights especially those of women and children are a relative issue.

In the bigger picture, the subcontinent still seems trapped in its history. Even at the most glorious period of the Mughal and Maratha empires with coffers spilling with bounty, opulent palaces and vast armies, the majority of the populace lived in abject poverty, ignorance and serfdom. It is sobering to contrast that at the time the Mughal emperor Shah Jahan was spending a fortune to build the Taj Mahal in the memory of his beloved wife who died giving birth to his 12th child, the King of Sweden was initiating the first nationwide midwifery training program to provide safe motherhood. The colonial powers which replaced them, fared no better as they deliberately fostered a feudal and hierarchical administrative structure to enable them to govern a large and disparate landmass. It is time to break this mind set. The recent recognition that poor health is a part rather than a conse-quence of poverty is a welcome trend in this direction, as is the link between socio- economic inequalities, poverty and health seeking behavior(18-20). Is the issue one of state allocation to primary care rather than generating economic growth and private income benefits? Some of us would forcibly argue that the provision of basic primary health care services, adequate nutrition and education are basic human rights. The relative amount of resources available for the health and social sectors thus do matter, as primary care is an issue of basic rights and state responsibility and can hardly be left to market forces. Can we plead a lack of resources and poor economies? More than any international market forces operating in South Asia and structural adjustments, the issue of paltry resource allocations for health, nutrition and education assumes enormous importance when one views the relative spending on conventional as well as nuclear weapons and delivery systems in India and Pakistan.

For a region that houses almost two thirds of the world’s malnourished children(21), this wanton waste of resources and opportunity is nothing short of criminal. Given the well- established link between investments in early childhood development, nutrition and long term development(22), this makes little sense. The global super powers are often criticised for their wanton spending on weapons and armaments, but closer to home, the arguments for striking a balance of arsenal in South Asia are particularly facile and tenuous(23). A conservative estimate of the annual expense of maintaining the nuclear arsenals of both countries indicates that the funds would be more than sufficient to provide an extra daily nutritional supplement to all malnourished women and children and to routinely include hepatitis-B and Hib vaccines in the EPI program. The silence on such issues by the thousands of members of the Pediatrician fraternity in India and Pakistan is something that history will undoubtedly pass judgement on, perhaps in less than adulatory terms.

The ordinary Indian and Pakistani daily wage earner is the salt-of-the-earth, far removed from the vested interests and festering conflict on our borders. No large-scale investments in health are possible without diverting vital resources away from senseless military spending to peace. It is time that war was waged instead on the real and common enemies of the subcontinent, namely ignorance, illiteracy, gender inequity, un-employment and grinding poverty. Who will take on the cudgels for this, except for the custodians of child health and rights for almost half a billion children and adolescents in the region? While the exact intervention and development models may vary, the principles of investing in human development and basic human rights are universal, and need to be emulated for the whole region. I believe strongly that this is a multidisciplinary and multisectoral responsibility. The creation of pressure groups to direct resources and efforts in these regards is the key. The fortunate few among us who can peer through the looking glass and see the subcontinents’ health contrasted with the rest of the world, owe this to the women and children.

Funding: None.
Competing interests: None stated.

Zulfiqar Ahmed Bhutta,
The Husein Lalji Dewraj Professor of 
Pediatrics and Child Health,
The Aga Khan University,
P.O. Box 3500,
Stadium Road,
Karachi 74800, Pakistan.
E-mail: [email protected]

1. Yusufzai M, Bhutta ZA. In: Contemporary Issues in Childhood Diarrhea and Malnutrition. Ed. Bhutta ZA. Oxford University Press, Karachi, 2000; pp 1-22.

2. Bhutta ZA. Why has so little changed in maternal and child health in south Asia? Br Med J 2000; 321: 809-812.

3. Measham AR, Chatterjee M. Wasting Away: The Crisis of Malnutrition in India. The World Bank, Washington DC, 1999.

4. Ramalingaswami V, Jonsson U, Rohde J. The Asian enigma. In: Progress of Nations, UNICEF, New York, 1996, pp 11-17.

5. Mahbub ul Haq. Human Development Center. Human Development in South Asia. The Gender Question. Oxford, Karachi, 2000.

6. Feachem RGA. Poverty and inequity: A proper focus for the new century. Bull WHO 2000; 78: 1-2.

7. Benatar S. Global disparities in health and human rights: A commentary. Am J Public Health 1998; 88: 295-300.

8. Kumar S. World Bank’s policy of structural adjustment under fire in India. Lancet 1997; 350: 1233.

9. Social Policy and Development Center. Social Development in Pakistan: Annual Review 2000. Oxford, Karachi, 2000.

10. Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: Evidence from Brazilian child health studies. Lancet 2000; 356: 1093-1098.

11. Joseph KS. The Matthew effect in health development. Br Med J 1989; 298: 1497-1498.

12. Dzakpasu S, Joseph KS, Kramer MS, Allen AC. The Matthew Effect: Infant mortality in Canada and internationally. Pediatrics 2000; 106: e5.

13. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: Field trial in rural India. Lancet 1999; 354: 1955-1961.

14. Anand K, Kant S, Kumar G, Kapoor SK. "Development" is not essential to reduce infant mortality rate in India: Experience from the Ballabgarh project. J Epidemiol Community Health 2000; 54: 247-253.

15. Sen A. Health in development. Bull WHO 1999; 77: 619-623

16. Johnsson U. An approach to human rights-based programming in UNICEF (Eastern and Southern Africa). SCN News 2000; 20: 6-9.

17. World Health Organization. World Health Report 2000. Health Systems: Improving Performance. Geneva, World Health Organization, 2000.

18. Makinen M, Waters H, Rauch M, Almagam-betova N, Bitran R, Gilson L, et al. Inequalities in health care use and expenditures: Emperical data from eight developing countries and countries in transition. Bull WHO 2000; 78: 55-65.

19. Filmer D, Pritchett L. The impact of public spending on health: does money matter? Soc Sci Med 1999; 49: 1309-1323.

20. Osmani S. Poverty and Nutrition in South Asia. In: Nutrition and Poverty. ACC/SCN Symposium Report. Nutrition Policy Paper # 16, November 1997.

21. Gillespie S. Malnutrition in South Asia: A Regional Profile. UNICEF Regional Office for South Asia, Kathmandu,1997.

22. Young ME. Early Child Development: Investing in Our Children’s Future. Elsevier, Amsterdam, 1997.

23. Bhutta ZA. Staring into the abyss: walking the nuclear tightrope in South Asia. Br Med J 1998; 317: 363-364.

* "Unto every one that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath" [Matthew 25:29 (King James version)].