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Summary: More than 12 million children under the
age of five still die needlessly each
year from "diseases of poverty,"
including immunizable childhood
diseases, malaria, intestinal and
respiratory infections, lack of food
and clean water, violence, and lack of
primary health care. Copies of this and other Minnesota Advocates for Human Rights reports
are available from: Minnesota Advocates for Human Rights,
http://www1.umn.edu/humanrts/mnadvocates/mahr/children/execsum.htm
Executive Summary
We are guilty of many errors and many faults, but our worst crime is
abandoning the children, neglecting the fountain of life. Many of the
things we need can wait. The Child cannot. Right now is the time his
bones are being formed, his blood is being made and his senses being
developed. To him we cannot answer "Tomorrow." His name is "Today."
-Gabriela Mistral, Chilean Poet and Nobel Laureate
Summary and background
More than 12 million children under the age of five still die
needlessly each year from "diseases of poverty," including
immunizable childhood diseases, malaria, intestinal and respiratory
infections, lack of food and clean water, violence, and lack of
primary health care. These avoidable child deaths are unconscionable
at a time when preventative and curative measures are available and
remarkably cost-effective. Advances in child survival have reached
only a portion of children around the world. Even within
industrialized nations, significant disparities in infant and child
mortality persist.
The continuing worldwide crisis of excessive child mortality is not
only a tragedy, it is a human rights violation. Recent global efforts
to reduce child mortality reflect both remarkable successes and
dismal failures. Although dramatic improvements in child survival
have occurred in the past 50 years, many innocent children are still
denied the chance to live to see their fifth birthday. Without their
most fundamental human right-the right to survive-no other human
rights have meaning. The Convention on the Rights of the Child is the
most widely ratified international human rights treaty in history. It
recognizes the child's inherent right to life and articulates the
obligation of governments to "ensure to the maximum extent possible
the survival and development of the child." This obligation includes
a guarantee to "a standard of living adequate for the child's
physical, mental, spiritual, moral, and social development"
regardless of the child's gender, race, or socioeconomic status. The
Convention repre
sents the minimum standards for children's rights. The failure of
ratifying governments to provide all their infants and children
conditions adequate for survival and healthy development violates
these minimum standards.
This report outlines the interdependence between health and human
rights. It analyzes the international standards that are breached by
avoidable child deaths and defines the responsibilities of
governments to protect the fundamental human rights of their
children. A commitment to the protection of these rights by
governments and the international community is critical to ensure
that every child has an equal chance to live and develop.
High rates of child mortality worldwide are caused by the combined
effects of biological, behavioral, and socioeconomic factors. The
immediate cause of a child's death is usually a biological event such
as an infection. A behavioral factor on the part of the parent or
care provider, such as delay in seeking health care for the child,
may also contribute to the death. Most child deaths are accompanied
by underlying structural or socioeconomic factors. In many cases,
impoverishment, lack of basic necessities, prohibitive costs of
health care, lack of social services, and the inferior status of
women in a society all contribute to high levels of child mortality.
An understanding of the interconnection of these causes is essential
to the development of effective strategies to increase child survival.
This report describes the specific obligations under international
human rights law for the protection of child survival and health.
While sustainable social and economic development is indispensable to
child survival, it may also prevent other human tragedies. A respect
for the full range of human rights protected under international law
will improve child survival and provide a clear mechanism to
determine policy and programmatic priorities. In addition to
increased child survival, a respect for human rights will improve the
health and livelihood of women and enhance socioeconomic conditions
for the entire population.
This report uses a case study approach to analyze the child survival
situation in three countries of varying levels of development-Uganda,
Mexico, and the United States. The report also sets forth the
relevant obligations under international human rights law and makes
recommendations for measures to increase child survival and health.
Findings of this report
Global child survival has improved since the 1950s but the benefits
reach only a portion of the world's children. Children in developing
countries are more likely to die before reaching age five than
children in developed countries. Uganda's children under age five
face a child mortality rate that is one of the world's worst at 147
deaths per 1000 live births. In Mexico, mortality rates of children
under five have fallen considerably; however, these rates are still
disproportionately high for its development level and comparatively
higher than those of other middle income countries. In the United
States, the overall rate of infant mortality ranks worse than 20
other developed countries. The death rate among U.S. Black infants is
even higher than those of developing countries such as Costa Rica,
Cuba, and Sri Lanka.
In both developing and developed countries, poor people, racial and
ethnic minorities, and indigenous groups have disproportionately
higher rates of child mortality. In Uganda, over 60 percent of the
total population live in poverty and 90 percent of the people reside
in rural areas. Across the country, one in six Ugandan children dies
before reaching age five. In Mexico, the situation is equally
compelling. Mexican children from poor and rural areas, where the
incidence of poverty among indigenous populations exceeds 80 percent,
are most susceptible to preventable deaths. The U.S. case example
reveals that gross disparities in infant and child mortality rates
persist among different population groups in the country. Poor
children and Black children are the most vulnerable in the United
States. Black infants die at more than twice the rate of White
infants. The mortality rate among U.S. infants from poor families is
60 percent higher than for infants above the poverty level.
Data on issues critical to child mortality are inadequate and are not
disaggregated in a manner useful to developing effective policies and
programs. In many countries, data are kept on the overall rate of
child mortality while data on the specific circumstances of
individual deaths or the regions where the deaths occur are not
adequately recorded. Overall child mortality rates mask important
variations among population groups within a country. In Mexico, data
on child mortality collected by the government are unreliable. First,
the information varies widely by sources within the country and is
inconsistent with data collected by UNICEF. Second, government data
on child mortality are lacking for regions where large numbers of
indigenous people live. Similarly, in the United States significant
discrepancies exist in the collection of data useful for
understanding and preventing the underlying causes of disparities in
infant mortality. For example, although vital records of births and
deaths are the primary dat
a sources for understanding patterns of infant mortality in the
United States, information about the household income status of
infants at the time of their birth or death is not included in these
records.
Children under age five are dying primarily from preventable causes
that include biological, behavioral, and socioeconomic determinants.
In developing countries, child deaths are caused largely by the
"diseases of poverty" such as immunizable childhood diseases and
malnutrition. The low socioeconomic status of mothers, unsafe water,
lack of nutritious food, and punitive government policies also
contribute to excessive child deaths. In industrialized countries,
children often die from low birth weight and preterm births, abuse
and neglect, and accidental injuries. As in non-industrialized
countries, socioeconomic factors impact child survival in
industrialized countries.
Structural factors which contribute to child mortality include
absolute poverty, lack of basic necessities, discrimination,
unbalanced macroeconomic policies, and unsustainable external debts.
Resource disparities among population groups generally parallel the
disparities in child death rates in these groups. The Uganda case
study illustrates the formidable constraints to improving child
survival and health in a developing country. Uganda is one of the
poorest and most heavily indebted countries in the world. Child and
maternal mortality rates are among the world's highest, while access
to essential health care and safe water lags far behind. The low
social status and high illiteracy of women in Uganda undermine the
health of children as well as women.
In Mexico, persistent socioeconomic inequities are exacerbated by
economic and structural adjustment policies. Government economic
policies have been biased toward urban centers at the expense of
marginalized areas. In the past decade, the Mexican government has
systematically pursued austerity and structural adjustment programs
in accordance with World Bank and IMF specifications. This process
has aggravated inequities in socioeconomic development between urban
and rural areas. The Mexican government has treated issues such as
poverty and disparities in child mortality rates as acceptable
consequences of the country's economic development, rather than
violations of economic, social, and cultural rights. As a result,
child mortality is viewed as inevitable rather than preventable.
The United States has seen dramatic changes in public benefits for
health care and social welfare since the 1980s. U.S. strategies for
reducing infant mortality have had mixed success in the last two
decades. "Reforms" in the social and health delivery systems, if not
carefully scrutinized, may undermine the improvements that have been
made and increase infant and child health differentials between
socioeconomic classes. This pattern is especially troubling in light
of the projected increase in the percentage of disadvantaged children
in the United States. The child poverty rate has already grown to
nearly 22 percent and is now the highest in the industrialized world.
Ameliorative measures are available and affordable. A global strategy
to promote "Health for All by the Year 2000," which was proposed at
the 1978 Alma-Ata International Conference on Primary Health Care and
adopted by the World Health Assembly in 1981, provides a practical
framework for improving child health and survival worldwide. The
20:20 initiative suggests a strategy through which aid donors and
governments can earmark 20 percent of their budgets towards meeting
the social goal of universal access to primary health care and
nutrition, reproductive health, water and sanitation, primary
education, and other basic social services. U.N. agencies as UNICEF,
UNFPA, WHO, UNDP, and UNESCO endorsed the 20:20 initiative in 1994.
In spite of these global strategies, basic child survival strategies
in Uganda remain under-funded. The government dedicates greater
resources to defense spending, the debt burden, and low-impact,
tertiary health care. Uganda has not succeeded in carrying out its
plans to improve child s
urvival by moving resources away from curative, hospital-based
programs to primary and preventative health care.
The Mexican government's response to preventable child mortality in
marginalized areas remains inadequate. While Mexico's domestic laws,
institutions, and administrative programs appear consistent with the
Alma-Ata primary health care approach, they do not support long-term
solutions to the problem of preventable child mortality. Rather,
government programs to reduce child mortality are framed in terms of
short-term poverty alleviation or social assistance. Health and
social programs are often politicized and do not adequately address
the disparity in child survival nor the underlying socioeconomic
conditions which threaten the health and survival of children.
In 1990, the United States government adopted its own national
initiative called Healthy People 2000 which sets specific objectives
for achieving health for all U.S. residents by the year 2000. Healthy
People 2000 emphasizes the reduction of persistent disparities in
health between certain groups who bear the disproportionate burdens
of poor health and the population at large. The country's gross
disparities in infant mortality are associated with the racial and
ethnic background as well as the gender and socioeconomic status of
various population groups. Although overall health has improved,
health conditions for some disadvantaged groups have deteriorated.
The status of Black infants as compared to White infants is an apt
illustration. Use of prenatal care has improved for both Blacks and
Whites, but remains significantly higher for Whites. The incidence of
low birth weight remains stable for Whites and has increased for
Blacks. The disparity in Black and White infant deaths rates is
growing. It now appear
s unlikely that the main objective in reducing racial disparities in
U.S. infant health can be achieved by the target year.
Disparate levels of avoidable child deaths reflect a failure on the
part of governments to respect and ensure the basic guarantees
essential to child survival. Child survival is a predicate to the
enjoyment of all other human rights. Of the three countries studied
in this report, only the United States has not ratified the
Convention on the Rights of the Child. The United States has,
however, ratified the International Covenant on Civil and Political
Rights and the Convention on the Elimination of Racial
Discrimination, which require the government to protect its children
against racial discrimination in health and development. The widening
disparity in infant mortality and in the socioeconomic status of its
citizens points to a general failure on the part of the U.S.
government to meet international standards to protect and provide for
the human rights of all its children.
Although the Mexican government has ratified and adopted
international instruments relevant to child health and survival,
Mexico has not effectively complied with its international
obligations to protect the basic guarantees to life, health, and non-
discrimination. Despite domestic laws and programs related to health,
Mexico has not adequately protected the health and survival rights of
poor, rural, or indigenous children. Increasing socioeconomic and
child survival disparities in marginalized communities constitute
discrimination, violating international law.
Uganda's domestic law places a priority on child welfare, however,
legal and resource limitations hinder the protection of children's
rights. The 1995 Constitution of Uganda recognizes and protects the
right to life, but contains no explicit guarantee of the right to
health. In addition, the enforcement provisions of the Constitution
do not apply to the right to health. The Children's Statute of 1996
specifies children's rights and places shared responsibility for
ensuring those rights on the nation, parents, extended families, and
local authorities. In practice the country faces the enormous
challenge of marshaling adequate human and financial resources to
implement these guarantees.
General recommendations
To governments
Take all necessary steps to assure basic and fundamental human
rights, including:
right to non-discrimination;
right to life;
right to health;
right to an adequate standard of living, which includes:
> sufficient food
> appropriate housing
> safe water and sanitation
> adequate medical services; and
right to education.
Fully comply with human rights treaties and instruments, in
particular, the Convention on the Rights of the Child.
Observe the Alma-Ata principles of primary health care by ensuring
equity, universality, community participation, and intersectoral
collaboration in health policies and programs. All segments of the
population must be enabled to define and guide their own well-being.
Adopt a cohesive strategy for child survival that promotes long-term
investments and solutions, and de-emphasizes short-term measures. In
particular:
operate child survival programs that include:
universal immunization
oral rehydration therapy
micronutrient supplemental and nutrition programs
breast-feeding promotion
reproductive health and family planning services
epidemic control and prevention;
improve environmental conditions such as access to good sanitation
and safe water, instead of reliance on oral rehydration therapy alone;
enact equitable food policies (e.g., equitable distribution of income
and food sources, famine prevention, targeted food supplementation,
and stabilization of food prices), rather than targeted
micronutrient/food supplementation alone;
monitor and evaluate the status of children through a permanent
system for periodic collection of reliable disaggregated data; and,
fund on-going research on children's issues to shape policies and
programs.
Take legal and policy measures to ensure that the status and role of
women will improve the quality of their life as well as the health
and welfare of their children and family. In particular:
take all necessary steps to fully comply with the Convention on the
Elimination of All Forms of Discrimination Against Women;
guarantee by law and practice that all women have universal access to
health and education, economic opportunity, and improved standards of
living;
provide resources to ensure equality in gender relations within the
family structure and the larger society.
Accede to the United Nations' 20:20 initiative that calls for a
prioritized resource allocation towards basic health and social
development: a minimum allocation of 20 percent of governmental
budgets and 20 percent of donor countries' official development
assistance.
Comply with obligations under international human rights law to
assist poorer countries in realizing the rights essential to the
survival and health of children.
Develop an organized public education and advocacy program to
heighten awareness of the need to improve maternal and infant health
that should be directed toward the general public, women of
childbearing age, families, teachers, and employers.
To international financial institutions
Ensure that finance and economic development programs do not
disadvantage poor, rural, and agrarian regions by focusing only on
urban centers and the global market.
Continue the joint initiative of debt relief and poverty reduction in
development policy and program planning. A more progressive debt
reduction plan must be considered for all poor countries,
particularly indebted countries that have a demonstrated commitment
to the social sector, institutional and human capacity building,
poverty alleviation, and development of a democratic and civil
society.
Apply a social conditionality on future loans as a strategy to compel
loan-recipient countries to mobilize greater national resources
specifically for health and social development.
To U.N. specialized agencies and international health/development non-
governmental organizations
Emphasize ratification and observance of human rights treaties,
especially those which guarantee rights related to child health and
survival, including:
International Covenant on Political and Civil Rights;
International Covenant on Economic, Social, and Cultural Rights;
International Convention on the Elimination of All Forms of
Discrimination;
Convention on the Rights of the Child; and
Convention on the Elimination of All Forms of Discrimination Against
Women.
Continue active involvement in the monitoring of global child
survival and health. Facilitate the work of the Convention on the
Rights of the Child, the International Covenant on Economic, Social
and Cultural Rights, and the Convention on the Elimination of All
Forms of Discrimination Against Women. Improve the selection and
collection of appropriate (disaggregated) social and health
indicators to measure more accurately the impacts of policies and
programs.
Facilitate and improve the linkages between U.N. specialized
agencies, international health and development (non-governmental)
organizations, governments, and international financial institutions
to improve child survival through national planning and
implementation.
Promote primary health care objectives that are low-cost, high-
impact, and appropriate to local situations.
Support long-term, grass-roots development that improves social
conditions and human capacity in a sustainable manner.
Country-specific recommendations
Uganda
Comply with all human rights obligations under treaties and
instruments to which Uganda is a party.
Promote and protect children's rights, in particular those related to
child health and survival, through adequate programs and funding.
Continue legislative efforts as well as target social spending to
promote the rights and status of women. Government funds should
support the implementation of a massive women's literacy campaign.
Repeal or update provisions of the Public Health Law that are
inconsistent with the Local Governments Act. Increase the resources
available to the Ministry of Health and Local Councils to guarantee
the implementation of reasonable minimum health standards regardless
of the wealth of the various districts. The cost sharing scheme for
the health sector should be re-examined and modified to ensure
accessibility to the poor.
Provide funds to support high-impact primary health care strategies
as a national priority, including the required human capacity
resources outlined in the Uganda National Plan of Action for Children
reform program. Funds made available from the current IMF and World
Bank debt relief initiative provide an excellent opportunity to
invest in the Uganda National Plan of Action for Children primary
health care package.
Use debt relief funds effectively and sustainably to increase child
survival. After demonstrating the impact of debt relief on child
survival, more IMF and World Bank debt should be forgiven.
Target rural communities in the provision of health and social
service funds.
Mexico
Comply with all human rights obligations under treaties and
instruments to which Mexico is a party.
Promote and protect children's rights, in particular rights related
to child health and survival, through adequate programs and funding.
Combat preventable childhood deaths and diseases among all segments
of the population as a national health priority to which the maximum
available resources must be allocated.
Adopt a cohesive strategy for child health and survival which
promotes long-term investments and solutions to alleviate underlying
socioeconomic disparities in marginalized areas, including:
poverty: reorient socioeconomic development policies to redress the
devastating impacts in rural and poor communities resulting from
World Bank/IMF austerity programs, and government biases and
"reforms";
malnutrition: establish equitable food policies which promote self-
sufficiency through food production and livable wages rather than
dependency on micronutrient/food supplementation subsidies;
lack of clean water, basic sanitation, and safe housing: improve
environmental conditions to prevent childhood diseases resulting from
unsafe housing and water, and lack of basic sanitation systems; and
lack of health and social services: ensure affordable, accessible,
and quality health and social services, especially for women and
children, which take into account the socioeconomic and cultural
concerns of marginalized, particularly indigenous, populations.
Observe the Alma-Ata principles of primary health care by ensuring
equity, universality, community participation, and intersectoral
collaboration in health policies and programs. All segments of the
population must be enabled to define and guide their own well-being.
Improve the productive life and health of women, particularly rural
women, as well as the welfare of their children and families.
Target resources to poor and rural communities, and implement urgent
measures to ensure balanced and equitable economic growth in both
urban and rural areas.
Correct inconsistencies in child health data, with particular
attention to issues of validity and reliability, and utilize
disaggregated indicators for vulnerable populations.
Consult nongovernmental organizations and consider their information
and recommendations in health policies and programs.
United States of America
Ratify the Convention on the Rights of the Child, the International
Covenant of Economic, Social and Cultural Rights, and the Convention
on the Elimination of All Forms of Discrimination Against Women.
Ensure implementation and compliance with all human rights
obligations under treaties and instruments to which the U.S. is a
party.
Promote and protect children's rights, in particular rights related
to child health and survival, through adequate programs and funding.
Achieve further reductions in the disparity in infant mortality and
morbidity. Such reductions require changes in social and economic
barriers to healthy pregnancy and birth outcome. Both the public and
private sectors should increase their investment in health care
coverage, child care, education, and training.
Ensure that the changes in public benefits and health-care delivery
do not further threaten child health and survival.
Implement strategies that minimize the risks of unintentional
injuries and violence toward children. Prevention of child abuse and
neglect should focus on the millions of high-risk families who are
living below the poverty line or are plagued by domestic violence and
substance abuse-major risk factors for child ill-treatment.
Adopt an integrated policy on children's health and well-being in
both the federal and state governments, addressing not only the
medical needs of all expectant mothers and newborns, but also
investing in broad-based preventive approaches.
Strengthen coordination between state and federal programs and social
and health services for women and their children. A comprehensive
service delivery system is needed, offering perinatal clinical
services and linkages between community-based health care and social
services.
Increase funding at the state and federal level for monitoring, data
collection, and research on the status of children's health and well-
being.
The Child Survival Project of Minnesota Advocates for Human Rights
invites and encourages comment on this report, which is part of an
overall strategy to build support for promoting economic, social and
cultural rights. This report is intended to serve as a catalyst for
future research and advocacy.
Over the next two years, the Child Survival Project will bring
together a coalition of new constituents and resources for promoting
child survival through public education and advocacy. The Project
will assist human rights and health advocates, educators, lawyers,
parents, health and development professionals, and policy makers, to
work collaboratively to protect the basic rights of vulnerable
children and to lower the rates of child mortality. The process of
implementing human rights guarantees invokes mechanisms that can
promote child survival. At national and local levels, laws, policies,
and programs can be assessed in light of a government's international
human rights obligations. At the international level, advocates can
use international and regional bodies, such as the Committee on the
Rights of the Child and UNICEF, to present information about a
country's compliance with its obligations under international law and
advocate for corresponding international assistance and pressure.