2003_17

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Presidential Address
World Medical Association, Helsinki 13th
September 2003
Dr James Appleyard,
President of World Medical Association
Dear friends and colleagues. {in Finnish}
Distinguished guests, ladies and gentlemen.
It is a great honour and privilege to follow Katy Myllymaki and her eminent predecessors as your
President. Our continuing challenge is to maintain and promote the professional values that
underpin medical practice worldwide.
It is good to be in Helsinki, home of our hosts the Finnish Medical Association. Three years ago
the Finnish Medical Association celebrated their 90th
birthday with the theme “Pro humanitate”.
At the ceremony, the Emeritus Archbishop of Helsinki encouraged us to reaffirm our
professional mission internalising our shared values, as our professional conscience. Our
conscience becomes our “compass” in the everyday practice of medicine and for our role as
teachers and leaders in the field of healthcare.
So what I want to talk to you about is at the heart of the patient-physician relationship – our
respect for the individual patient.
Our Hippocratic tradition recognises the “rights” of our patients who entrust themselves to our
care. Respect for these “rights”, nurtured by our profession, is essential for the survival and
development of communities and nations. That respect is the greatest bulwark against violence
and terrorism. At the core of this respect is the recognition of the “rights’ of our children.
As my mentor, Professor Billy Andrews, the author of the Bill of Rights of the Child in United
Sates in 1964 wrote:
“The level of civilisation attained by any society will be determined by the attention it has paid to
the welfare of its infants and children”.
So what I want to look at is some of the problems that face our children worldwide and how we
can provide leadership to solve them in an atmosphere of participation, partnership and
practical action.
Children are a country’s most valuable resource. Poverty and the denial of children’s rights a
have a devastating affect on our children’s survival. For poor people health is crucial and yet
worldwide it is the poor who carry the heaviest burden of the life threatening illnesses –
diarrhoea, malnutrition, malaria, measles, HIV/AIDS and TB.
The World Health Organisation’s Commission on Macro-economics and Health has recognised
that substantially improved health outcomes are a pre-requisite if developing countries are to
breakout from the cycle of poverty. Healthy children learn better and with improvement in health
and education less children are conceived and less children die.
Some 25years ago a study on the “value of children” was conducted in 9 countries comparing
the parents motivations for child bearing. It found that in less developed countries where
children were born to be used for economic reasons there was a relatively high fertility rate.
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More affluent countries had a lower fertility rate when children were conceived for what was
termed their “psychological” value, each child being valued for their own sake.
The “demographic dividend” of valued children and healthier children has been shown to be the
most important source of growth of capital income for low income countries.
Numerous studies in the developed world” have found that the legacy of “a lost childhood
creates an ‘underclass’ of citizens who are ‘social misfits’. Intervention in the form of support
and parent empowerment in the early years pays enormous emotional dividends long-term.
So what can we do?
We should ask questions of ourselves and of our governments – why?
Why when we can produce enough food in the world to feed the world is malnutrition implicated
in more that half the deaths in the world of children under 5 years of age. Malnutrition is a
cause as well as a consequence of poverty. And the number of malnourished children in sub-
Saharan Africa has increased over the last 10 years.
Why do people spend money on cigarettes rather than food for their children?
Recent research shows that even other peoples smoking adds an extra 9% on the burden of
illness in children.
More than 5 million children alive today will die prematurely of smoking related diseases.
Tobacco companies must cease to market to kids and poor counties.
All countries need to sign up to the UN Framework Convention on Tobacco control.
Why the want for water?
About 1.2 billion people lack access to safe drinking water, 2.4 billion lack adequate sanitation
giving rise to diarrhoea, cholera and trachoma. In poor countries it has been estimated that at
any one time half of the urban population is suffering from one or more of the diseases
associated with the lack of water and proper sanitation. This lack of safe drinking water and
poor sanitation is among the major causes of child deaths, illnesses and malnutrition. The
incidence of diarrhoea can be reduced by nearly a quarter and the number of deaths by close to
2/3rds through improvements in safe water supply with sanitation and hygiene.
Why do we spend up to 10 times more on methods of killing people than of saving their
lives?
More children have suffered from armed conflicts and violence in the last 10 years than in any
other comparable period in history –ethnic conflicts and civil wars have come in the wake of the
end of the ‘cold war’. Conflicts killed 2 million children in the 90’s. They left large numbers of
children disabled and psychologically scarred. Children have been displaced, in unsanitary
conditions with poor or absent social infrastructure and no system of justice. There are 35
million displaced persons and refugees 80% of whom are women and children. Surely our
children deserve a just and peaceful world.
Why do we seem to condone the use and abuse of children by our inaction?
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Children are increasingly becoming victims of abuse, neglect and exploitation with child
prostitution, sex tourism and child slavery. There may be some 35 million child victims
worldwide.
One form of a gross breach of the rights of young girls is Female Genital Mutilation. Even in the
UK where the practice is outlawed it is widely alleged that FGM continues to be practiced in
private hospitals. Girls are being sent abroad to countries where the operation is allowed (Joint
Committee on Human Rights 10th
Report Houses of Lords and Commons).
Why AIDS?
The HIV/AIDS pandemic is a global disaster – there are 10.4 million aids orphans 95% of whom
are in sub Saharan Africa. In children under 5yrs, the virus will cause a devastating 2/3 of
deaths in Botswana, half the deaths in Zimbabwe and S Africa.
Why is the gap between rich and poor nations getting wider with the digital divide
becoming greater?
Since 1960 the disparity between industrialised and developing countries has more than tripled.
Yet the international aid effort slackened in the 90s.The official development assistance (ODA)
fell back to its all time low in 2000. It was 0.22% of the combined GNP of developed countries.
In the late 90s, a survey of 30 developing countries found that on average only 12-14% of
government spending was on basic social and health services.
This level of investment in our children is shameful and so short sighted.
How do the nations and countries of the world compare in caring for their children?
UNICEF published useful comparative ‘league’ tables of the Under Five years Mortality rates
per 1000 live births. This is a sensitive index of how countries value and care for their children.
These tables also raise a lot of unanswered questions.
Top of the UNICEF “list” in 2001 was Sweden with an under five mortality rate of only three per
1000 live births. Bottom of the table of 195 nations was Sierra Leone with 316 children under
five per 1000 births dying each year. A difference of 100 fold between the top and the bottom
nations.
Nearly one third of all children in Sierra Leone die before the age of five – what a catastrophic
sacrifice of human life and human potential for a country to make.
On the other hand, some less rich countries such as Slovenia, Greece and the Czech Republic
have overtaken the much richer countries of United States and United Kingdom in their UNICEF
listings.
Why?
With a Gross National Incomes per capita of 1,170$ Cuba manages to achieve an under five
mortality rate of only nine. Whilst Kuwait which has 17 times more money to spend per capita
achieves a rate of 10.
Uganda, one of the poorest counties, has a low Gross National Income per capita of 280$ pa,
very similar to Tanzania. Uganda has managed to save an additional 50,000 children’s lives
per year as compared with ten years ago. The rate in Tanzania has virtually remained
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unchanged. Iraq with seven times the individual wealth of Uganda has suffered an extra 66,840
child deaths under five per year in 2001 then it did ten years ago. In 1990 the U5M rate in Iraq
was 50 per 1000 births. In 2001 it had risen to 133 deaths per 1000 births. Just think of it – an
additional 66,840 children per year had been allowed to die in Iraq.
The test of the new “regime” will be how it treats its children. Iraq has traditionally had high
standards of medical education and medical care.
How come the world is paying so little attention to the 20,000 extra children under five who are
dying per year in Zimbabwe in 2001 as compared to 1990. A human sacrifice that no country
nor indeed the world can afford to allow. How can we afford not to change?
How can we affect change?
There are clear and well-trodden pathways to progress but why do we only crawl along these
when we should be running to catch up?
First and foremost it requires a recognition and positive implementation of the UN Declaration of
the Rights of the Child and placing children in the centre of our thoughts for the future.
This means that all governments should examine the impact of all their policies on the health of
children.
Each of our national medical associations must ensure our own Association’s Declaration of
Ottawa built on the UN Declaration is adopted in each country throughout the world.
We need to participate, work in partnerships and promote practical solutions. These should
embrace all the range of initiatives with governments, with non-government organisations and
other health care providers. We must create robust infra-structures in all countries that allow
proper access to safe water, stable food, sound education and secure healthcare for families
and communities.
There are widespread barriers to progress that need to be broken down – barriers even at
WHO level.
Why for instance do 7 million children in Taiwan remain excluded from WHO services. They are
described as WHO orphans. Surely it is not beyond the wit of who to focus on the children first
and provide political solutions second. Political solutions are much more likely to flow from the
acceptance of the equality of children and their rights worldwide.
The World Summit for Children’s ‘Plan of Action’ in 1990 called on governments to prepare
national programme of actions to implement World Summit commitments on children in a co-
ordinated and strategic way. 155 countries have prepared these “NPA’s” for children. All the
countries need to do this.
It is this incorporation of the children into mainstream developmental thinking that will produce
results. In Brazil, India, Uganda and elsewhere action plans for children are formed as part of
the State and district development plans.
Local communities however often struggle to meet the needs of children without their fair share
of resources. In the 1990’s the WHO’s 20/20 initiative was based on the premise that the
average 20% of the National budget in developing countries and 20% of Official Development
Assistance was sufficient to achieve universal access to basic social and health services.
However most countries seriously under invest in these basic social and health services.
Studies carried out in some developing countries have indicated that in the 1990s basic social
services including health education, clean water, and sanitation received on average only
between 12% and 14% of the national budget.
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On average only 11% of Official Development Assistance from richer countries was allocated to
these services. To make things worse heavily indebted poor countries have had to cut their
health budget to meet their debts.
Under investment in basic social and health services was a major reason why several of the
World Summit’s children’s goals had not been met.
We simply must spend more of our money on our children and you must tell your finance
ministers to do so.
The cost of realising universal access to health, water, sanitation, education was estimated by
the United Nations and World Bank to be an additional 70 -80 billion per year in 1995 prices. We
can and must afford this.
Developing countries spent on average more on defence than either basic education or basic
health care. Levels of defence spending by developed countries were about 10 times the level
of spending allocated to international development. This is a grievous, grim and grisly distortion
of priorities that puts a premium on suffering and death above health and happiness.
Well integrated programmes for children in early childhood and the support of families especially
those in high risk situations are now widely understood to be powerful investments and have
lasting effects both for children and the overall economic development. Appropriate intervention
with adolescents can also have profound benefits for children borne to young parents. In the
1990’sthere was a dramatic increase in the evidence that the education and the healthy growth
of children was crucial to the future economic process and broke the cycle of poverty. Investing
in children from the earliest years must rest as the core of the long term development of all of
our societies.
It is up to us through the WMA to ensure our national medical associations implement the
Declaration of Ottawa, and during the next year I will be seeking the responses from all our
national medical associations on the progress towards implementing our Declaration of Ottawa.
It’s up to us to insist that all governments look at the impact of all their decisions on child health.
It is up to us and each one of us to be strong advocates for the needs of our child patients and It
is up to us and each one of us to influence our local community leaders throughout the world to
ensure that the services they provide reflect the same values of the needs of their children.
It is up to each one of us to act through the various international non-governmental
organisations such as UNICEF, Save the Children who do enormously good work throughout
the world and we can give a helping hand more directly through other groups focussing on
individual children and the local communities such as PLAN and World Vision.
So each of us individually by active participation in these partnerships can make a practical
difference to the health of our children and the future of the world.
I end with a quote from Nelson Mandela and Graca Machel:
“We cannot waste our precious children. Not another one, not another day. It is long past the
time for us to act on their behalf”.