Correspondence
SDGs: start with maternal, newborn, and child health cluster On July 19, 2014, the UN Open Working Group, which had been working for 18 months, adopted by acclamation a set of Sustainable Development Goals (SDGs) to send to the UN Secretary General and General Assembly in September, 2014, for consideration. The Open Working Group proposed 17 goals and 169 targets for a 15 year period from 2015 to 2030. Setting such a large number of priorities has the potential to dilute focus and deflate the inspiration for action. Compounding the issues of focus and inspiring action, consider the practical challenges of executing these many goals and targets, raising appropriate financing, and ensuring appropriate measurement frameworks. There is a solution: launch clusters of targets for the SDGs in a rolling fashion over a period of 5 years. Maternal, newborn, and child cluster would be an ideal start. Maternal, newborn, and child health was featured prominently in the original Millennium Development Goals and continues to galvanise global support. The UN Secretary General has embraced maternal, newborn, and child health in his Every Woman Every Child initiative, and Canadian Prime Minister Stephen Harper launched the Muskoka initiative and recently renewed it with a CAN$3·5 billion commitment at the Saving Every Woman Every Child: Within Arm’s Reach Summit (held in Toronto, ON, Canada, in May, 2014). On the basis of the present draft of the SDGs, we suggest a maternal, newborn, and child health cluster of 13 targets (panel) that are interdependent, focus on the same beneficiaries and crucial to achieve sustainable development. The ultimate outcomes are reducing maternal mortality (target 3·1) and reducing child mortality (target 3·2). The remaining targets focus on how to reach these ultimate outcomes. www.thelancet.com Vol 384 September 20, 2014
Deaths in the newborn period constitute a shocking 42% of all deaths in children younger than 5 years and these can be addressed by access to quality essential health-care services related to antenatal, perinatal, and postnatal care (target 3·8). Stunting and wasting are key underlying causes of both child mortality and impaired child development (target 2·2). Pneumonia and diarrhoea contribute substantially to child mortality, including in the newborn period; malaria, AIDS, tuberculosis, and measles are top killers of children in the postneonatal period (target 3·3). Many of these infectious diseases can be prevented by vaccines (target 3·8). Many maternal and child complications are related to early pregnancy and inadequate birth spacing, which can be prevented by family planning and ending early and forced marriage (targets 3·7 and 5·3). Underlying these issues, and also impeding access to care, is discrimination against women and girls (target 5·1). A key factor underlying both maternal and child mortality working through waterborne disease and malnutrition, as well as the microbiome, is sanitation (target 6·2). Almost all the risks above that cause child deaths also threaten children’s developing brains and to address them not only saves lives but also saves brains to help children to develop and reach their full potential. We recently argued1 that it will not be possible to end poverty without addressing early child development, and proposed the following target: reduce by 50% the number of children who fail to reach their full economic and social potential later in life. Recent evidence from Pakistan2 and Jamaica3,4 has shown that, for child development, stimulation is at least as important as nutrition and there is ample evidence of the economic payoff of early child education (target 4·2). Moreover, toxic stress, which impairs brain development, is mitigated through child protection (targets 5·2 and 16·2). Finally, without birth registration (target 16·9), children will not have
access to key life-saving services and we will not have accurate information to gauge progress and accountability. There is a big gap between setting goals and achieving them. Launching post-2015 goals in a rolling fashion will honour the many voices that set the goals, while increasing the likelihood that the vision articulated will ever be realised. We declare no competing interests.
*Karlee L Silver, Peter A Singer [email protected] Grand Challenges Canada, Toronto, ON M5G 1L7, Canada
For the draft of the SDGs see http://sustainabledevelopment. un.org/focussdgs.html Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
Panel: Maternal, newborn, and child health cluster of post-2015 Sustainable Development Goal targets • 2·2 by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant, and lactating women, and older persons • 3·1 by 2030 reduce the global maternal mortality ratio to less than 70 per 100 000 livebirths • 3·2 by 2030 end preventable deaths of newborns and under-5 children • 3·3 by 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, waterborne diseases, and other communicable diseases • 3·7 by 2030 ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes • 3·8 achieve universal health coverage, including financial risk protection; access to quality essential health-care services; and access to safe, effective, quality, and affordable essential medicines and vaccines for all • 4·2 by 2030 ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education • 5·1 end all forms of discrimination against all women and girls everywhere • 5·2 eliminate all forms of violence against all women and girls in public and private spheres, including trafficking and sexual and other types of exploitation • 5·3 eliminate all harmful practices, such as child, early, and forced marriage and female genital mutilations • 6·2 by 2030 achieve access to adequate and equitable sanitation and hygiene, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations • 16·2 end abuse, exploitation, trafficking, and all forms of violence and torture against children • 16·9 by 2030 provide legal identity for all, including birth registration
1093
Correspondence
1 2
3
4
Silver KL, Singer PA. A focus on child development. Science 2014; 345: 121. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014; published online June 17. http://dx.doi.org/10.1016/S01406736(14)60455-4. Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 2005; 366: 1804–07. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science 2014; 344: 998–1001.
Global health and the media We commend Pamela Das and Gabriela Sotomayor for shining a light on WHO and its recent handling of communications at the 67th World Health Assembly (June 21, p 2102).1 What this article also touches on is the role of the media and global health more broadly. Health advocates already struggle to make core public health issues headline news and at the forefront of people’s minds. With a record-breaking number of agenda items, World Health Assembly briefings with the media should have been proportionate to new developments and changes being made to communicate these effectively and appropriately. The media have a responsibility to communicate with the public responsibly. And health advocates have a responsibility to communicate stories with the media. History has shown that when they do, positive change might be stimulated—as seen with HIV and enhanced access to antiretrovirals. The media is a powerful force for good and WHO needs to prioritise these relationships. Neglect the media and the issues are overlooked. A report2 by independent think tank Chatham House on governance and 1094
WHO suggests the complexity of WHO as an organisation. With reform on the agenda, media and communication necessitate a central role. Article 2 of the WHO constitution, about the functions of the organisation, emphasises the need “to provide information, counsel and assistance in the field of health”,3 which is clearly essential “to assist in developing an informed public opinion among all peoples on matters of health”3 and needs partnership with the media to achieve that goal. Systems need to be in place to respond to questions and points of clarification by those tasked with spreading new ideas and developments—otherwise an absence of clarity will lead to no dissemination. Twitter and Facebook posts cannot substitute briefings with the press. We urge WHO to respond in time for the 68th World Health Assembly. We declare no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London WC2R 2LS, UK (JRF); Global Health Film initiative, Royal Society of Medicine, London, UK (JRF, LB); and Department of Global Health, London, UK (LB) 1
2
3
Das P, Sotomayor G. WHO and the media: a major impediment to global health? Lancet 2014; 383: 2102–04. Clift C. What’s the World Health Organization for? Final Report from the Centre on Global Health Security Working Group on Health Governance. 2014. http://www.chathamhouse. org/sites/files/chathamhouse/field/field_docu ment/20140521WHOHealthGovernanceClift. pdf (accessed June 30, 2014). WHO. Constitution of the World Health Organization. 2005. http://apps.who.int/gb/ bd/PDF/bd47/EN/constitution-en.pdf (accessed June 30, 2014).
Human schistosomiasis: an emerging threat for Europe In their Seminar, Daniel Colley and colleagues (June 28, p 2253)1 described the epidemiology of human schistosomiasis, but it is important
to acknowledge that schistosomiasis is now becoming a European disease. The Mediterranean area is a former settlement of Bulinus and climate warming creates favourable conditions for local transmission in southern Europe. The emergence of urinary schistosomiasis in Corsica (France), with a decade of native cases around Europe, might mean that schistosomiasis is now a cause for concern in Europe.2,3 Also, many travellers (migrants or tourists) come back from endemic areas after being contaminated through contact with water. Among travellers, the European armed forces have many cases of schistosomiasis because of their deployments in Africa (especially Côte d’Ivoire, Mali, and Central African Republic).4 Clinical examination has low sensibility and specificity (one of three people are asymptomatic).1,4,5 European physicians have to manage this new situation. Medical education enhancement would improve their clinical sensibility. Nowadays, unexplained chronic urinary or digestive symptoms should evoke suspicion of schistosomiasis. Biological screening should be systematically done in these patients and in travellers with water contact in endemic countries, whatever their symptomatology. Finally, epidemiological surveillance should permit the detection of clusters around cases and monitor the spread of the local transmission. We declare no competing interests.
*Franck de Laval, Hélène Savini, Elodie Biance-Valero, Fabrice Simon [email protected] French Military Center for Epidemiology and Public Health, CESPA, Camp de Sainte Marthe, 13014 Marseille, France (FdV); Department of Infectious Diseases and Tropical Medicine, Laveran Military Teaching Hospital, Marseille, France (HS, FS); and Department of Biology, Robert Picqué Military Teaching Hospital, Bordeaux, France (EB-V) 1
2
Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet 2014; 383: 2253–64. ProMED-mail. Schistosomiasis—France: (Corsica). Archive Number 20140518.2480187. 2014. http://www.promedmail.org (accessed Sept 3, 2014).
www.thelancet.com Vol 384 September 20, 2014
SDGs: start with maternal, newborn, and child health cluster On July 19, 2014, the UN Open Working Group, which had been working for 18 months, adopted by acclamation a set of Sustainable Development Goals (SDGs) to send to the UN Secretary General and General Assembly in September, 2014, for consideration. The Open Working Group proposed 17 goals and 169 targets for a 15 year period from 2015 to 2030. Setting such a large number of priorities has the potential to dilute focus and deflate the inspiration for action. Compounding the issues of focus and inspiring action, consider the practical challenges of executing these many goals and targets, raising appropriate financing, and ensuring appropriate measurement frameworks. There is a solution: launch clusters of targets for the SDGs in a rolling fashion over a period of 5 years. Maternal, newborn, and child cluster would be an ideal start. Maternal, newborn, and child health was featured prominently in the original Millennium Development Goals and continues to galvanise global support. The UN Secretary General has embraced maternal, newborn, and child health in his Every Woman Every Child initiative, and Canadian Prime Minister Stephen Harper launched the Muskoka initiative and recently renewed it with a CAN$3·5 billion commitment at the Saving Every Woman Every Child: Within Arm’s Reach Summit (held in Toronto, ON, Canada, in May, 2014). On the basis of the present draft of the SDGs, we suggest a maternal, newborn, and child health cluster of 13 targets (panel) that are interdependent, focus on the same beneficiaries and crucial to achieve sustainable development. The ultimate outcomes are reducing maternal mortality (target 3·1) and reducing child mortality (target 3·2). The remaining targets focus on how to reach these ultimate outcomes. www.thelancet.com Vol 384 September 20, 2014
Deaths in the newborn period constitute a shocking 42% of all deaths in children younger than 5 years and these can be addressed by access to quality essential health-care services related to antenatal, perinatal, and postnatal care (target 3·8). Stunting and wasting are key underlying causes of both child mortality and impaired child development (target 2·2). Pneumonia and diarrhoea contribute substantially to child mortality, including in the newborn period; malaria, AIDS, tuberculosis, and measles are top killers of children in the postneonatal period (target 3·3). Many of these infectious diseases can be prevented by vaccines (target 3·8). Many maternal and child complications are related to early pregnancy and inadequate birth spacing, which can be prevented by family planning and ending early and forced marriage (targets 3·7 and 5·3). Underlying these issues, and also impeding access to care, is discrimination against women and girls (target 5·1). A key factor underlying both maternal and child mortality working through waterborne disease and malnutrition, as well as the microbiome, is sanitation (target 6·2). Almost all the risks above that cause child deaths also threaten children’s developing brains and to address them not only saves lives but also saves brains to help children to develop and reach their full potential. We recently argued1 that it will not be possible to end poverty without addressing early child development, and proposed the following target: reduce by 50% the number of children who fail to reach their full economic and social potential later in life. Recent evidence from Pakistan2 and Jamaica3,4 has shown that, for child development, stimulation is at least as important as nutrition and there is ample evidence of the economic payoff of early child education (target 4·2). Moreover, toxic stress, which impairs brain development, is mitigated through child protection (targets 5·2 and 16·2). Finally, without birth registration (target 16·9), children will not have
access to key life-saving services and we will not have accurate information to gauge progress and accountability. There is a big gap between setting goals and achieving them. Launching post-2015 goals in a rolling fashion will honour the many voices that set the goals, while increasing the likelihood that the vision articulated will ever be realised. We declare no competing interests.
*Karlee L Silver, Peter A Singer [email protected] Grand Challenges Canada, Toronto, ON M5G 1L7, Canada
For the draft of the SDGs see http://sustainabledevelopment. un.org/focussdgs.html Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
Panel: Maternal, newborn, and child health cluster of post-2015 Sustainable Development Goal targets • 2·2 by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant, and lactating women, and older persons • 3·1 by 2030 reduce the global maternal mortality ratio to less than 70 per 100 000 livebirths • 3·2 by 2030 end preventable deaths of newborns and under-5 children • 3·3 by 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, waterborne diseases, and other communicable diseases • 3·7 by 2030 ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes • 3·8 achieve universal health coverage, including financial risk protection; access to quality essential health-care services; and access to safe, effective, quality, and affordable essential medicines and vaccines for all • 4·2 by 2030 ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education • 5·1 end all forms of discrimination against all women and girls everywhere • 5·2 eliminate all forms of violence against all women and girls in public and private spheres, including trafficking and sexual and other types of exploitation • 5·3 eliminate all harmful practices, such as child, early, and forced marriage and female genital mutilations • 6·2 by 2030 achieve access to adequate and equitable sanitation and hygiene, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations • 16·2 end abuse, exploitation, trafficking, and all forms of violence and torture against children • 16·9 by 2030 provide legal identity for all, including birth registration
1093
Correspondence
1 2
3
4
Silver KL, Singer PA. A focus on child development. Science 2014; 345: 121. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014; published online June 17. http://dx.doi.org/10.1016/S01406736(14)60455-4. Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 2005; 366: 1804–07. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science 2014; 344: 998–1001.
Global health and the media We commend Pamela Das and Gabriela Sotomayor for shining a light on WHO and its recent handling of communications at the 67th World Health Assembly (June 21, p 2102).1 What this article also touches on is the role of the media and global health more broadly. Health advocates already struggle to make core public health issues headline news and at the forefront of people’s minds. With a record-breaking number of agenda items, World Health Assembly briefings with the media should have been proportionate to new developments and changes being made to communicate these effectively and appropriately. The media have a responsibility to communicate with the public responsibly. And health advocates have a responsibility to communicate stories with the media. History has shown that when they do, positive change might be stimulated—as seen with HIV and enhanced access to antiretrovirals. The media is a powerful force for good and WHO needs to prioritise these relationships. Neglect the media and the issues are overlooked. A report2 by independent think tank Chatham House on governance and 1094
WHO suggests the complexity of WHO as an organisation. With reform on the agenda, media and communication necessitate a central role. Article 2 of the WHO constitution, about the functions of the organisation, emphasises the need “to provide information, counsel and assistance in the field of health”,3 which is clearly essential “to assist in developing an informed public opinion among all peoples on matters of health”3 and needs partnership with the media to achieve that goal. Systems need to be in place to respond to questions and points of clarification by those tasked with spreading new ideas and developments—otherwise an absence of clarity will lead to no dissemination. Twitter and Facebook posts cannot substitute briefings with the press. We urge WHO to respond in time for the 68th World Health Assembly. We declare no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London WC2R 2LS, UK (JRF); Global Health Film initiative, Royal Society of Medicine, London, UK (JRF, LB); and Department of Global Health, London, UK (LB) 1
2
3
Das P, Sotomayor G. WHO and the media: a major impediment to global health? Lancet 2014; 383: 2102–04. Clift C. What’s the World Health Organization for? Final Report from the Centre on Global Health Security Working Group on Health Governance. 2014. http://www.chathamhouse. org/sites/files/chathamhouse/field/field_docu ment/20140521WHOHealthGovernanceClift. pdf (accessed June 30, 2014). WHO. Constitution of the World Health Organization. 2005. http://apps.who.int/gb/ bd/PDF/bd47/EN/constitution-en.pdf (accessed June 30, 2014).
Human schistosomiasis: an emerging threat for Europe In their Seminar, Daniel Colley and colleagues (June 28, p 2253)1 described the epidemiology of human schistosomiasis, but it is important
to acknowledge that schistosomiasis is now becoming a European disease. The Mediterranean area is a former settlement of Bulinus and climate warming creates favourable conditions for local transmission in southern Europe. The emergence of urinary schistosomiasis in Corsica (France), with a decade of native cases around Europe, might mean that schistosomiasis is now a cause for concern in Europe.2,3 Also, many travellers (migrants or tourists) come back from endemic areas after being contaminated through contact with water. Among travellers, the European armed forces have many cases of schistosomiasis because of their deployments in Africa (especially Côte d’Ivoire, Mali, and Central African Republic).4 Clinical examination has low sensibility and specificity (one of three people are asymptomatic).1,4,5 European physicians have to manage this new situation. Medical education enhancement would improve their clinical sensibility. Nowadays, unexplained chronic urinary or digestive symptoms should evoke suspicion of schistosomiasis. Biological screening should be systematically done in these patients and in travellers with water contact in endemic countries, whatever their symptomatology. Finally, epidemiological surveillance should permit the detection of clusters around cases and monitor the spread of the local transmission. We declare no competing interests.
*Franck de Laval, Hélène Savini, Elodie Biance-Valero, Fabrice Simon [email protected] French Military Center for Epidemiology and Public Health, CESPA, Camp de Sainte Marthe, 13014 Marseille, France (FdV); Department of Infectious Diseases and Tropical Medicine, Laveran Military Teaching Hospital, Marseille, France (HS, FS); and Department of Biology, Robert Picqué Military Teaching Hospital, Bordeaux, France (EB-V) 1
2
Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet 2014; 383: 2253–64. ProMED-mail. Schistosomiasis—France: (Corsica). Archive Number 20140518.2480187. 2014. http://www.promedmail.org (accessed Sept 3, 2014).
www.thelancet.com Vol 384 September 20, 2014
