Women and children first

By Paul Farmer
The Rotarian - April 2009
The following is an excerpt from the In Focus section in the April 2009 issue.

To make a stable world, we need to recognize the powerful link between maternal health and the well-being of children. The author tells why.

These days, everyone in my line of work (medicine and public health) wants to have straightforward and attainable goals, clear standards of measurement, and an obvious - to use the most common parlance, these days - return on investment. For over a century, in medicine and public health, this was called "the search for the magic bullet." By the late 19th century, effective vaccines were looking like magic bullets, and as efficacy increased and adverse affects decreased, hundreds of millions of lives were saved, and untold misery prevented. One scourge, smallpox, was driven from the earth. Even without using concepts such as grief or sorrow, concepts worthy of respect in public health, that was certainly a handsome return on investment. It's one of the reasons that Rotary chose to devote so much time and energy to making sure that the world's children do not die of vaccine-preventable illness.

But there is no magic bullet for child survival if we hope to meet the aspirations laid out in the United Nation's Millennium Development Goals, which are meant to complement each other. Goal 4 is to reduce child mortality, but all eight are meant to "recognize explicitly the interdependence between growth, poverty reduction and sustainable development." If a child survives measles only to succumb later to a waterborne disease like typhoid, then surely this must be tallied as a loss. One might say that waterborne diseases render certain vaccines less effective, since the desired rate of return is that every child live a healthy life, go to school, enjoy her (or his) family, and one day have a job and a family of her own. We don't yet have sophisticated and agreed-upon standards for these sorts of dignified aspirations, but that doesn't mean we shouldn't try to develop them and marshal efforts to meet these goals.

A common expression in Haiti - everyone is human (tout moun se moun), - is usually invoked to describe the inhumane conditions to which the poor are so often exposed. A 1985 community survey in southern Haiti pegged rural maternal mortality at 1,400 deaths per 100,000 live births. In comparison, maternal mortality in the United States in 2005 was 14 per 100,000. (Zero maternal deaths were registered in 2005 in Iceland.) Other studies from Haiti, including more recent ones, reveal the unsurprising fact that among the poor, maternal survival often determines child survival. In a study designed to determine the odds of child survival when a mother dies, and conducted in rural southern Haiti between 1997 and 1999, it was concluded that "if a family experiences a maternal death, that family has a 55.0% increased odds of experiencing the loss of a child under 12, whereas when a non maternal death occurs, no increased odds exists." Similar studies conducted in rural Africa, from Uganda to the Gambia, show similar results.

But as public health initiatives have become more "vertical," seeking to focus on only one outcome (whether AIDS prevention or child survival or eradication of river blindness), it has been harder to find funding for comprehensive primary care. And user fees remain a curse for the poorest and most vulnerable. Including safe motherhood in child-survival efforts remains an urgent task in much of the world, and these services should be considered "public goods for public health" rather than commodities to be bought and sold.

Worldwide, over 500,000 women die of pregnancy-related causes every year - more than 90 percent live in Africa or Asia, and almost all are poor by any standard. Obscene though it is, death during childbirth isn't the end of the story. In the poorest parts of the world, a mother's death often means destitution for her surviving children. Within a few years, many orphaned children wind up in terrible straits, sometimes resorting to desperate or criminal measures for food, shelter, clothes, or school fees. This is a familiar scenario to doctors working in rural Haiti or rural Africa. But even in less impoverished settings, such as Palestine, studies have shown that motherless children, especially girls, are much more likely to suffer from malnutrition. They are less likely to attend school - again barred by user fees they cannot afford.

Although there are no magic bullets that would allow us to meet all of the Millennium Development Goals, making sure that there are more comprehensive views on child survival, and more comprehensive programs available to poor families, is the best way to promote the broader agenda of social justice and sustainable development.

The ideas may be visionary, but now more than ever we must pursue many of the very projects that are often dismissed as unreasonable, naive, unsustainable, or not cost-effective. We need to take heart from such instances and conclude that it is precisely in times of economic downturn that social safety nets must be expanded and strengthened. Child-survival programs, like efforts to lessen maternal mortality, need to be embedded in broader efforts to promote the basic rights of all to freedom from want. Utopian, yes. But this should be the ultimate goal of the global health movement that links so many of us, in the public and private sectors, and the return on investment that we all demand.