In 2015 at the UN the governments of the world on all our behalf committed to 17 Sustainable Development Goals.
I want to talk about SDG 3: how we can ensure healthy lives and promote wellbeing for all at all ages. As a pediatrician I’ll be focusing on young children because we know that the first thousand days from conception into the third year of life sets the life course for all that follows. Investments at this young age achieves a better return than at any other stage of life. This is Badock’s Wood Children’s Centre, here in Bristol. One of 22 children’s centres across the city designed to help families care for young children and encourage their development. Community-based centres like this one are vital in providing focus for preventative early intervention that significantly improves wellbeing for children and their families.
Whilst we aspire to wellbeing for all children, for many of the world’s youngest and poorest early life can still be a battle for survival. Before I came to Bristol I worked in East Africa and South Asia, where we maintain partnerships with colleagues to this day. When I arrived in rural Ethiopia 25 years ago it was not uncommon to meet families who’d lost 1 in 5 of their children before their fifth birthday. Here in Bristol it used to be much the same. Before we consider how we might help all children achieve wellbeing it is instructive to consider what progress we’ve made with child survival.
We can study trends using this Gapminder world web graph which shows trends in child mortality over time. On the Y-axis is child mortality expressed as the number of child deaths before the age of five for every thousand children born, whilst the X-axis is a measure of income using a notional currency adjusted for differences in purchasing power.
Each bubble represents a different country: the bigger the bubble, the bigger the population.
The regions are colour-coded: red for Asia, blue for Africa, green for the Americas and yellow for Europe. If we set the timer here to 1800 we can see that the child survival story was grim everywhere across the world at the outset of the Industrial Revolution. In the United Kingdom, for instance, for every 1,000 children born in 1800 we would expect 329 not to survive past their fifth birthday. Running the time trend forwards we can see that as industrialised economies generated wealth, child mortality levels fall. If we freeze the trend in 1945 we can see Europe and America has pulled away from the red and blue of Asia and Africa.
Focusing on the UK in 1945 the mortality had fallen to 55 out of every thousand. This change reflects the improvements in what we now term the social determinants of health, those upstream factors like wealth, education which result in downstream improvements in housing, sanitation, diet. Running the mortality trend graph until to the present day we find enormous progress in many countries, especially in Asia, where the benefits of decolonisation and wealth creation have been translated into huge gains in child survival. These post-war child health gains were accelerated in the 1970s by primary care programs championed by UNICEF, the United Nations Children’s Fund, which help developing countries to build their own
infrastructure for mass immunisation and what we now call ‘WASH’: water, sanitation and, all importantly, hygienic practices like hand-washing with soap. This step forward became known as the first child survival revolution, which unfortunately stalled in the 1990s as the free-market philosophy took hold and reduced investments in public infrastructure. The forerunners of the SDGs, the Millennium Development Goals, refocused our efforts at the turn of the millennium, with goals aiming for reducing poverty, improving education for all, and health, which had a child survival goal, MDG 4, to reduce child mortality by two-thirds. This triggered what has been termed the ‘second child survival revolution’.
Using the most rigorous scientific methodology to assess the impact of interventions like insecticide-treated bed nets and oral rehydration therapy, we are now making sustained progress against some of humankind’s greatest scourges like malaria and diarrhoeal disease. But despite these efforts, by 2015 MDG 4 had not been reached by 50 countries. One reason for this is the continuing high rates of early death in the first month of life, the newborn period, so if we are to meet the 2030 targets of SDG 3 our grand health challenge now is to reduce the deaths of newborn infants in low-income countries.
Applying the methods of the second child survival revolution, we need to identify cost-effective interventions to prevent premature birth, facilitate clean and safe delivery and promote healthy early life. Prevention is always better than cure, and women themselves can help find the answers. An emergency fund used to pay for transport to hospital should labour go off-course, safe delivery kits containing a clean blade, bar of soap, plastic sheet and clean thread, even stretchers to carry the labouring mother over the hills of Nepal. This participatory approach, when trialled, can reduce neonatal deaths by a third.
So women’s groups, whether in rural Nepal or children’s centres like this one in Southmead in Bristol, seem to be helpful in bringing young families and their infants together, helping us towards ensuring healthy lives and promote wellbeing whether in Southmead, Bristol or Kathmandu, Nepal.