The 3Ds in march towards millennium development goals

Professor Sanath Lamabadusuriya was recently inducted as President of the Sri Lanka Medical Association. Published here are extracts from his Presidential Address

The Millennium Development Goals (MDGs) were established in September 2000 by 189 heads of state who adopted the UN Millennium Declaration and endorsed a framework for development. The target date was identified as 2015. The aims of the MDGs are to reduce poverty and hunger, tackle ill health, improve literacy, promote gender equality, provide access to clean water and prevent environmental degradation.

As a practising paediatrician for nearly 40 years the areas covered by the MDGs have been very close to my heart. Therefore I thought that the March Towards the Millennium Development Goals (MDGs) would be an appropriate theme for this year.

If one compares the disease burden in the developing world with that of the industrialised world, issues such as survival of newborns, nutritional problems and environmental pollution etc. are common to both groups. In the developing world other main health problems are pneumonia, diarrhoea, malaria, HIV/AIDS, TB and measles. In contrast in the industrialised world the other main health issues are birth defects, accidents, murder / suicide/ violence, heart disease and cancer. This is because in the latter group of countries, infections have been drastically reduced.

Prof. Lamabadusuriya delivering his address

Paediatricians working world-wide are closely involved with the MDGs. They already address many aspects of MDGs in their daily professional lives and in fact have been doing so for many decades long before the MDGs were established. They should be proud of this! Paediatric societies are encouraged to develop projects addressing one or several actions of the IPA millennium call for action. This will be good for child health at country level and for the global paediatric community.

As recently as in 2010, 8.8 million under the age of 5 years still died mainly from preventable or readily treatable diseases. Of these, 40% of babies were in the neonatal age group. Countless millions of other children will survive with impaired health and development. Approximately two thirds of these deaths are preventable. Nearly all these deaths are among the poor in the developing world. Under- nutrition contributes to one third of the deaths. Most of these children are found in Africa and South East Asia.

There are several general causes to explain why we are failing in global health issues. Poverty and its concomitants such as poor nutrition, poor hygiene, low literacy and a dirty environment contribute to it. Poor governance, due to rapidly changing governments in third world countries coupled with drastic changes in policy with every change of government is a major factor. In the developed world although governments change, there are no drastic changes in policies.

Third world politicians by and large fail to apply evidence based knowledge and therefore follow misguided policies. In some third world counties, lip service is paid to preventive health whilst the emphasis is on curative health. There is lack of health equity for children. Sometimes important vaccines that are available for use in the private sector are not found in a country’s National Immunisation Schedule. There is a sense of despair at times with lack of political and societal will. Underlying moral and ethical malfeasance plays a very important

underlying role.

There are paediatric causes as well to explain why we are failing in global child health. There is wide spread complacency with the current achievements. Tunnel vision may limit one’s plans to very specific issues. Some pediatricians live in ivory towers and are cut off from the community; there is inertia regarding international child health issues. Paediatricians in the Western world are mostly unaware of killer diseases such as Dengue fever which causes havoc especially in South East Asia. There is lack of academic momentum due to inadequate library and IT facilities in the case of paediatricians who work in rural areas. In a recent study, only 20% of paediatricians knew about MDGs!

What are the challenges ahead of us? These challenges mainly remain in the conflict affected and fragile states. More efforts and investments are required to prevent set backs and to accelerate progress. There is an urgent need to maintain better statistics. In Sri Lanka it takes two years for some vital statistics such as birth data and mortality data to be conveyed from the Registrar General’s Department to the Ministry of Health! As time is short (only five years more!) urgent action is needed.
Pneumonia is the biggest killer of children worldwide and accounts for almost 3 million deaths per year. Streptococcus pneumoniae (Pneumococcus) and Haemophilus influenza type B are the chief bacterial pathogens world-wide. We are fortunate that effective vaccines are available against both pathogens.

The Haemophilus influenza Type b vaccine (Hib Vaccine) was introduced to our national EPI schedule in the form of the pentavalent vaccine, few years ago. Prior to that the Hib vaccine had been available in the private sector for many years.

There are very effective vaccines against pneumococcal infections. Two types of vaccines are available; a conjugated vaccine for children under five years and a polysaccharide vaccine for older children and adults. Three polyvalent conjugated vaccines are currently available globally. This vaccine was routinely used for the first time in USA in 2000, and within a period of 10 years, there was a drastic reduction in pneumococcal infection in children under 5 years of age. Due to herd immunity, there was a significant reduction in the incidence of pneumococcal infection in their parents and grandparents as well.

This conjugated vaccine is routinely used in all developed counties. It was introduced recently to several developing countries such as Rwanda, Kenya and Pakistan through the assistance of GAVI. This vaccine has been available in the private sector in Sri Lanka for the last 2 years. It is a costly vaccine; each dose in Rs 9000.00 and 3 doses are required in infancy. Only a very few can afford it. Therefore, the need of the hour is to introduce the pneumococcal vaccine to our National EPI schedule with the assistance of GAVI. Vaccines do not save lives, but vaccination does!

There are specific paediatric issues for Sri Lanka. A special scenario exists where the Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and literacy rates are comparable with those in developed countries. However we need to reduce anaemia in infancy and childhood and improve the nutritional status of pre-school children (1-5 years). We need to provide essential micronutrients such as Zinc and Iron routinely to infants. Additional vaccines such as the pneumococcal vaccine and the rotavirus vaccine should be included in our National EPI schedule in the future.

To summarise, MDGs are a powerful force to reduce poverty and inequity globally. However, its progress is unequal and fragile. The need to reduce maternal and newborn deaths emerges as the most urgent and obvious priority. Investment in the health of women and children in a very comprehensive national health policy with appropriate strategy is extremely important.

What about the future of child health beyond the MDGs? There are other important health issues that have recently cropped up. There is a world wide increase in childhood obesity. Studies carried out by the academic staff of our own department of paediatrics has shown an alarming incidence of obesity in school children in Colombo. Diabetes mellitus is affecting children in large numbers. Up to 20 years ago, I could have counted the number of children with diabetes mellitus, I personally encountered, on the fingers of one hand. There has been an exponential increase during the last twenty years.

Our genes have remained the same; therefore it is due to environmental causes such as changes in life -styles and diet. The incidence of substance abuse among children is increasing. There are many disjointed family units due to migration, alcoholism etc. With more children surviving through intensive care in hospitals, the number of disabled children is increasing. There is a threat of emerging infections such as Novel influenza which has hit our shores recently. National disasters such as tsunamis, floods, earthquakes and earth slips continue to have a tremendous impact on populations and especially children.

Finally, I would like to highlight 3Ds for its future evolvement. D on dynamism - with a rapidly changing world scenario in all dimensions of illness and health, a formula given 10 years ago is likely to lose its viability. Hence emerging patterns should be under constant scrutiny and appropriate action taken. D on dispensation – in policy planning world-wide, the haves dispense for the have nots; powerful to less powerful. My plea is, in this dispensation, equity, lack of personal interest and ethical issues should be closely safeguarded. D on Development – Application of MDGs has mainly been with the developing countries in mind. Hence wider involvement of these countries as stakeholders, greater devolvement of power on decision making, will ensure the correct balance and the resultant sustainability that follows any project.

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