The past and future of child health, with Richard Horton

In 2019 there were 8.6m deaths globally among children and adolescents aged 0-20 years. Almost two decades on from The Lancet's first ever global health series, on child survival, we've published our new Series, Optimising Child and Adolescent Health and Development. Richard Horton reflects on the progress and setbacks across 20 years of child health and global health.

Read the full Series of papers:
Optimising Child and Adolescent Health and Development

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Transcript

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Jessamy: Hello and welcome to The Lancet Voice. It's May 2022 and I'm Jessamy Bagenal. In 2019, there were 8. 6 million deaths globally among children and adolescents aged 0 20 years, including stillbirths. 19 years ago, The Lancet published its first global health series on child survival. It highlighted the deaths of 10 million children each year, most from preventable causes and almost all in poor countries.

It galvanised a movement, and was the start of a new phase in the Lancet's history. Last week saw the launch of the Optimising Child and Adolescent Health and Development series, which again looked at child survival, and found that despite huge progress, Once again, the world is failing its children. I caught up with Richard Horton, editor in chief of The Lancet, to hear the story of this very special series and reflect on the last 20 years of global health.

So I thought we could start off with why this series means so much. What does it represent, Richard? 

Richard: It means so much to the journal and also personally to me because it was child survival that really got the lancet into the whole global health arena in modern times and I have to thank one person in particular for that and that's very much.

Jennifer Bryce, who, back in 2001, 2002, literally came into my office at the Lancet and shamed me by exposing my total lack of knowledge and understanding about the plight of over 10 million children who were dying before the age of five. And She proposed then that we should do a series looking at child survival and indeed we did.

We published that in 2003 2004. And that was really the beginning of our journey in global health. So this series 20, almost 20 years later is important because it is the first major update that we've done looking at the overall health of children. And there are some very important differences between the approach of this series compared with the child survival series 20 years ago.

And there are some very disturbing similarities as well. So it's an opportunity really to rethink our entire program of work on child health. 

Jessamy: Fascinating. And take us back to 2003. When that first series was published, what was going on in the world and how did it fit into that? 

Richard: That's a really great question, actually, because, everybody who's worked in child health remembers the era of Jim Grant, who was an executive director of UNICEF, and he actually started what was called the Child Survival Revolution.

And Those times where this focus was on being able to prevent deaths of young children was a seminal period in global health in the 70s and 80s. But by the time the late 1980s and the 1990s came around, the sad truth is that international institutions, countries, had taken their eye off the ball, and I think they thought that the job had been done, there wasn't much progress that could be made, and so you ended up at the very beginning of the Millennium Development Goal era, with over the, this num, terrible now thinking about it, this terrible figure of 10 or 11 million children under five who were dying for preventable causes.

So there was a real sense that WHO, UNICEF, the World Bank and governments in countries, about 100 countries where most children were dying. they just were not giving due attention to children and it was at the time that was then to really refocus what should be done and what the beauty of the series was that it wasn't just about criticizing people for not acting, the beauty of the series was that it was giving people cheap and highly deliverable interventions that could make a difference.

And if you look over the last 20 years, look at the progress. We've gone from something like 11 million under five deaths in 2002, 2003. Down to just over 5 million deaths now, over 50 percent reduction in mortality. There's no greater success story in global health than the child survival revolution that was kicked off in the early 2000s.

Jessamy: Brilliant. And, could you just tell us a little bit more about the major findings of this series then? These sort of big headlines but what are the sort of take home messages for you? 

Richard: I think what this series does is to, and I think we have to hold our hands up here because the Millennium Development Goal era was an era of great success for child health.

MDG for focused entirely on child survival and there really was that political commitment to getting child mortality down. Then when we went into the sustainable development goal era, health only had one goal, SDG3. There wasn't the focus on child health and I think where we are today is that we have gone back.

into an era of complacency and lack of investment and lack of political commitment. Now, we could just try and do more of the same, focusing on under five mortality, but that isn't going to work anymore. The world has moved on in the past 20 years. So what this series tries to do is completely reframe the future of the health of children and young people.

So we now go beyond under five mortality, both ways. Even earlier, we go back to preconception stage and we go and we try and bring in the two million deaths every year of stillbirths, which have been completely ignored. But at the same time, we go forward to take account of the health and well being of young people up to the age of 19, 20 years old, which we didn't do before.

We go beyond survival. So this series promotes the idea not just of saving lives, but what they call nurturing care. So that encompasses early child development, parental support, child maltreatment, a much more capacious view of well being, not just mortality alone. We go beyond coverage of interventions to focus upon quality, which we didn't do 20 years ago.

We don't just focus on health, we focus on the social determinants of health and that is the commercial determinants, environmental determinants in particular. And then finally, what we do is we don't just think about the health system, and that's all we thought about 20 years ago, and we really put a big emphasis on the importance of schools.

Schools are, It's so critical for the health of children and being and of course we all know that. It's just that, we all know that in our personal lives. It's just that in our professional lives we then forget it. But schools are important as platforms for the delivery of services.

Nutrition as well as health, but also as formative environments to shape the well being and the outlook and the aspirations of children and young people for their future, especially thinking about girls and young women. Really that's the ambition of the series. To totally reframe the way we think about children.

Jessamy: That's interesting. And I feel like I I'm gonna know the answer to this next question, but it would be great to hear you articulate it. What does that broader, wider approach represent in terms of from your point of view, the last 20 years of global health? What does it. What does this story of this original series to this series show more widely about global health and where we are now?

Richard: That's a really, that's a great question because it's requires you to think a little bit about some of the big changes in philosophy in global health that have taken place. And I think the changes that I would particularly focus on are around the following.

First of all, health is determined not just by the health system. The fact is that if you live in a very poor environment, whatever health interventions you're trying to deliver, if they don't take account of that broader environment, you're going to fail. So this series pays particular attention to addressing poverty as a major determinant of the well being and the health of children and young people.

And we didn't make that case 20 years ago. So this, the eradication of extreme poverty is crucial for this age group. And of course, in the time of a pandemic where well over 100 million people have been plunged back into extreme poverty, global health's going in reverse now, it's not going forward, then this context of poverty alleviation then becomes absolutely.

central. I think that 20 years ago, we didn't put as much emphasis as we are now on girls and young women. I think that we now have learned that the connection, for example, between maternal education and under five mortality and opportunities for Children is very important. closely linked. So unless you deal with the broader political and economic context of girls and young women, then you're going to miss out on opportunities for the health of their children.

And that's something that we just didn't talk about 20 years ago. And then I think the third point, which I, mentioned a moment ago is this emphasis on quality. One of the painful lessons that we've learned is that just delivering interventions on their own sometimes doesn't make any impact.

Because although you might have what you think is high coverage of interventions, particularly around maternal health, unless you have high quality, you can actually do more harm than good. So quality has to be at the heart of what you do. So I think those for me are the sort of three big changes that have shaped global health in this area over the past two decades.

Jessamy: Yeah, I think that resonates with me completely, particularly that aspect of women and girls and that kind of. Thinking about it from that perspective. And even though we've made this huge amount of progress, there still feels this disconnect. As you say, we're slightly in a stage of complacency, but we have these, very carefully crafted SDGs and a lot of rhetoric from politicians, global health leaders, et cetera, in support of action on child health.

But actually, fairly disappointing movement in actual gains. Recently, perhaps when we look at it over the last 20 years, there have been serious gains. But, why do you think there is that slight disconnect, or why are we in this period of complacency now? 

Richard: I think it's very clear that over the last five years we've really gone backwards on child, the health of children and young people, and I think if you, the reason for that is that we did have a golden era in the MDG time.

If you rewind and just think back to what happened, we had the child survival series in 2003. We had immediately UNICEF and WHO pick that agenda up. You then had the creation of the Partnership for Maternal, Newborn and Child Health, because we then did series on maternal health and newborn health and sexual reproductive health.

These separate movements started to get stitched together and PMNCH then became the chief advocate for that. Then Ban Ki moon created Every Woman, Every Child, which was his signature health initiative as UN Secretary General. And there was no question that Every Woman, Every Child was phenomenally successful.

successful at generating new investment into the health of women and children. But that ended in 2015. And when Antonio Gutierrez came in as secretary general, he dropped every woman, every child. We didn't have a specific SDG for women's and children's health. It got subsumed in SDG three. And frankly, the.

Gaze of global health drifted elsewhere. Now, I'm a great supporter of the campaign for universal health coverage, but one of the downsides of universal health coverage is that you then lose the specific vertical initiatives, which are so important. Now, we're very lucky to have the Global Fund to Fight AIDS, TB and Malaria.

HTB and Malaria had its own Millennium Development Goal but at the end of the MDG era, the focus on HTB and Malaria could continue because of the Global Fund. We didn't have a Global Fund for Women's and Children's Health, so once the political commitment ended in 2015, there was literally a vacuum, and that's where we are today.

So what we're trying to do with this. series is in a sense, we're exactly where we were in 2002, 2003. There's an enormous amount we know can make a difference. We've got this gap in terms of institutions and this gap in terms of investment, and we have to try and fill those gaps. And this is what the series is now trying to plug.

Jessamy: Excellent. And could you just tell us a little bit more about that in terms of course correcting over the next eight years? A couple of major things that you see could make real change and impact. 

Richard: What I really want to see, one of, again, what we learned for the past 20 years is, When you have a Secretary General of the United Nations, or a Director General of WHO, or an Executive Director of UNICEF, when they take up an initiative like this, and they really make it their number one priority, and they have the convening power to bring nations together and donors together to give money, that changes the landscape completely.

And when you can then get political leaders to step forward and pick these issues up. So we were so fortunate. The one political leader who really stepped up was Jens Stoltenberg. He was Prime Minister of Norway. A small country, but he picked up this issue, he invested in GAVI, he invested in MDGs 4 and 5, he turned up to meetings at the United Nations and led the convening of nations together to focus on these issues.

You need to have a head of state who will do that. So what we're trying to do here is we're trying to Encourage, optimistically, a little bit of provocation to Tedros, to the new executive director of UNICEF, to Antonio Gutierrez, and to any head of state out there who's willing to come and join us, to take this issue up, because we can guarantee That we can deliver political capital because we have the interventions, we have the knowledge, we know what will be successful, and this series lays it all out.

So we've got a ready made package that can deliver success. All we need now are the political leaders to take it up. 

Jessamy: Thanks, Richard.

Thanks so much for listening to this episode of The Lancet Voice. We'll be back in a couple of weeks time. Please subscribe to our podcast. You can find us on all your usual platforms.