Dr. Paul Wise opened his CLAS talk by admitting that the story he was about to tell is not new. On the screen in front of him, two photos were juxtaposed: one of a child looking very ill and one of her home, a decrepit shack that does nothing to protect her from the inclemency of the weather. Perhaps even more serious than the physical instability of the child’s home is its political precariousness, situated as it is in one of the world’s most unstable regions. This situation — “the juxtaposition of multiple serious clinical problems and a setting of profound material deprivation” as Wise described it — exemplifies the challenges that still face those seeking to improve global child health.
Historical Context
For decades now, the developed world has been looking for ways to help developing countries. International aid has traditionally focused on women and children, who generally are regarded as vulnerable and innocent victims of poverty, violence, and war. In his talk, Wise described the various approaches to maternal and child health that the international community has adopted over the years. In the 1960s and 70s, child and maternal health was viewed as dependent on economic development; and as a result, international aid took the form of economic assistance and, on occasion, humanitarian relief for natural disasters. Some critics, however, deemed these kinds of inter-ventions incomplete and called for more health-related, technical interventions.
In this context, the United Nations Children’s Fund (Unicef) launched the Campaign for Child Survival based on the GOBI strategy (Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization). The GOBI strategy was a focused, technical intervention designed to produce quick and significant improvements in child health. Despite the initiative’s success, there was a pushback in the 1990s from child advocates who regarded this approach as too narrow and unable to deal with issues that require fundamental social change, such as child labor or child soldiers. The United Nations again led the way, adopting the Convention on the Rights of the Child in 1989. Since then, the convention has been ratified by 192 countries — with the notable exception of the United States. Even though the convention has been regarded as a major step toward the wellbeing of children everywhere, deep concern remained that a focus on social reform tended to diminish technical efforts that respond directly to the fact that 70 percent of all child deaths are preventable. This tension in global child health — between social interventions and technical interventions, between social science and medicine, between lawyers and doctors — has persisted throughout the years. Paul Wise tries to overcome these tensions and marry the two in a new, integrated approach.
The Framework
Dr. Wise proposes a simple framework: any disparity in health outcomes can be explained either by differential underlying risk status or by differential access to effective interventions. At the center of these two concepts is the efficacy of the intervention. The more effective the intervention, the more important equitable access to that intervention is in determining a population’s health status. The framework’s very simplicity is controversial. Wise noted that it does not include words like “social determinants,” “prevention,” or “primary care.” For him, as long as the intervention is effective, it should be provided equitably to all those in need. Period.
Wise’s experience working in tumultuous settings has informed his framework. Those in regions at war, or recovering from war, not only have increased mortality due to direct effects like violence, but also due to indirect effects such as precarious living conditions and crumbling healthcare infrastructure. As the efficacy of medical interventions grows, so too grows the moral burden on our global community to provide those interventions — especially when they will save children’s lives. In this manner, efficacy and justice are inextricably linked since, as Wise says, the “non-provision of a highly efficacious intervention is unjust.” Based on this framework, Wise has devoted his life to developing an approach that will improve child health in areas of unstable governance through integrated political and technical strategies.
Implementing the Framework in Guatemala
Wise has been working in the highland area of Guatemala since the early 1970s, a region devastated by a 46-year civil war that claimed more than 200,000 lives and left 10 times that number disabled. The indirect effects of the civil war are estimated to be even larger. This is particularly true in the indigenous highlands, where recovery has been slow, and infant mortality rates are still high.
As part of Stanford University’s Children in Crisis initiative, Wise has spent many years working with local people and Stanford students in San Lucas Tolimán, an area surrounded by volcanoes in the middle of “coffee-country.” The goal of the program is to link “lifesaving child health interventions with the essential political requirements for providing them in the real world.” In Guatemala, this goal has been translated into a program that trains local volunteers to be promotores (health promoters) and schedules regular visits from Wise and Stanford students to support much-needed healthcare services for the local population. The promotores not only provide basic care and health education, they also frequently become community organizers.
The integration of health-service provision and community organization helped support an effort to engage the community, the Catholic Church, and the government to build new houses and get local people titles to the homes. These efforts resulted in the new owners investing in infrastructure such as latrines and roofing. Wise highlighted these results to show how social and health interventions can go hand in hand.
The assertion that health and social interventions are mutually reinforcing can sometimes be met with resistance: some argue that medical interventions are just a band-aid that can’t heal the wounds of social exclusion and oppression, while those in the health sector focus on technical interventions that can prevent or treat clinical diseases. The former argue that what really needs to be addressed are the “upstream” determinants of health, such as education, discrimination, and social class. The latter maintain that while these concerns warrant attention, there is great potential to improve health through the provision of highly effective technical interventions, such as immunizations and antibiotics. Wise argues that these positions must give way to an integrated strategy that recognizes that both fundamental determinants and life-saving technical capacity are tied to social justice and improved outcomes. “The death of any child is always a tragedy,” he said, “but the death of any child from preventable causes is always unjust.”
Although these perspectives have been validated by years of research, Wise makes a compelling argument that an integrated approach emphasizes the need to develop strategies that can improve maternal and child health in areas long plagued by inadequate or unstable governance. For this reason, Wise advocates for intense cross-disciplinary interaction between health experts, political scientists, and local community development workers in collective efforts to improve health services in areas of political unrest. “The majority of young child deaths in sub-Saharan Africa are occurring in places where most NGOs won’t go,” he said.
While groups such as Doctors Without Borders/Médecins Sans Frontières (MSF) provide critical health services in conflict areas, there may be a paucity of services once the active fighting is over. In contrast, Children in Crisis is not only concerned with health services in war zones but also in service provision in the years after the conflict is over, when poor governance and political instability may still persist. In addition, humanitarian organizations such as MSF often remain politically neutral in order to gain access to high-conflict areas, while the initiatives of concern to the Children in Crisis project focus explicitly on developing political strategies that permit essential health interventions.
The Future
The Children in Crisis program has been concerned with multiple geographic regions — from Zimbabwe to Eastern Congo, from the West Bank and Gaza to the favelas of Brazil. One of the main objectives of the program is to extend its reach to all children trapped in conflict areas and to help identify the political and health strategies that will prevent whatever modern medicine can prevent. Dr. Wise hopes that his program can be expanded to every place where there is political unrest.
It would be extremely interesting to see the Children in Crisis project advance the development of a research agenda that evaluates any programmatic successes that have occurred in areas of civil unrest and unstable governance. Since the pot of money to be distributed is limited — foreign aid represents less than 1 percent of the federal budget in the United States — and so many women and children continue to die from preventable causes in areas of political instability, there must be a serious reevaluation of the way health aid is distributed throughout the world.
Paul Wise is the Richard E. Behrman Professor of Child Health and Society and a professor of Pediatrics at Stanford University’s School of Medicine. He is also a senior fellow at the Freeman-Spogli Institute for International Studies at Stanford University. He spoke for CLAS on March 11, 2013.
