THE NINE PANELS
PANEL No. 1: The empowerment factor
PANEL No. 2: A national commitment to health and nutrition: Does everything start with a sound causal analysis?
PANEL No. 3 : Breaking out of the poverty cycle
PANEL No. 4 : An enhanced role for the caring of children
PANEL No. 5 : The right to know
PANEL No. 6 : The population/PHC/nutrition link
PANEL No. 7 : Never be sorry to be too late
PANEL No. 8 : Pressures imposed to address the economy: Do the people matter?
PANEL No. 9 : Other factors to reckon with in the 90s
Dev. In Practice, Vol.5, No.4, 1995.
CLAUDIO SCHUFTAN
schuftan@gmail.com
[*: This paper was prepared under UNICEF contract in preparation of the OAU/UNICEF/Donors meeting on held in November 1992 in Dakar; the meeting sought to launch a Decade of the African Child. African country papers reviewed were courtesy of the FAO/WHO ICN Secretariat. The contents of this paper focus on health and nutrition and are the exclusive responsibility of the author.]
By June 15, 1992, 31 African countries (19 francophone, 10 anglophone and 2 lusophone) had submitted their country papers for the forthcoming International Conference of Nutrition (ICN, Rome, December 1992).
These papers were reviewed, looking for challenges and windows of opportunity facing us in the years to come with a special focus on areas for potential future donor involvement. The review gives the donor community a unique insight into priority areas in need of attention during what may become the Decade of the African Child* – as perceived by almost 2/3 of the continent’s countries themselves. Through nine ensuing “panels” or “boxes”, the reader will get exposed to a spectrum of positive, contributing AAA cycles (assessment, analysis and action) at the different causal levels of the UNICEF conceptual framework of ill-health and malnutrition that deserve being promoted or strengthened in the next ten years; at the same time, some challenges requiring urgent attention (sometimes to neutralize negative, deterring AAA cycles) emerged from the same review.
Nothing spectacularly new arose from the review, nor can it be said that the actual recommendations for action made by the individual country papers were particularly strong. BUT, clearly, new emphases are being put on old and new problems, forcefully restating the sense of urgency attributed by African states to the health and nutrition problems of their children. Africa is ready to get on with the task of solving these, its own, problems. But African countries cannot do it alone. Herein lies the responsibility of the donor community in this new era where these very countries are taking initiatives themselves that deserve all international support (mainly moral, technical, material and financial); organizational resources can be (and are being!) mobilized locally.
A wide emerging consensus was found in the review of the country papers regarding an expressed need being voiced which in to foster systems that generically strive for sufficiency, stability, autonomy, sustainability and equity. Another trend that featured prominently in the review is the rapid integration of NGOs into the work on behalf of women and children in the continent. In the years to come, donors will surely want to bank-in more on this desirable shift. This, in itself, is an important and significant window of opportunity.
Through the review of these 31 papers, one was able to see that countries are doing whatever possible to ensure leaving the next generation an inheritance, better (or at least not worse) than the one enjoyed at present.
The process of putting these papers together and submitting them to the ICN Secretariat is to be seen as the linchpin for processes to come that will more forcefully further participation, accountability and transparency with respect to decision-making and action. The number of people from different sectors (government and non-governmental) that were involved in the process is, by itself, unprecedented. In this sense, there has indeed been a reawakening. Countries have actually learned a lot about themselves in the process. It is this consultative process that somehow needs to be kept alive, not by establishing new bureaucracies, but by involving society at large in resolving these multifaceted problems. Despite that, most of the follow-up action will initially revert back to the individual governments. Yet the real action will have to be at the national/decentralized, and hopefully more participative/democratized level. National plans are only a basis; they are the foundation for drawing up national strategies. One can thus actually build on these reports. But the process to carry out these strategies will be as important as the final outcomes expected. That is why these reports should be updated, reviewed and challenged annually. Donors should be prepared to come up with objective and critical appraisals of these reports (and perhaps funding for these yearly exercises). NGOs have already been constructively (though forcefully) critical of their country reports. One may want to set up follow-up units to monitor progress.
THE NINE PANELS
a. Windows of opportunity
The 9 panels that fallow refer to specific areas of inquiry that were used in the review of the 31 country papers and these were the following: (either the countries reported these components as already existing or they mentioned them explicitly in their future plans)
1. Participation/Emerging grassroots organizations involvement/ Adoption of a new development paradigm in which people are more considered as actors and their empowerment plays a growing and decisive role;
2. Policy reviews or new policies called for in which health and nutrition issues pertaining vulnerable groups become national priorities/Political commitment expressed towards health and nutrition activities/Nutrition as an ethical and human rights issue/Sound causality analysis carried out;
3. Links between income and health-nutritional status highlighted as crucial/Urban-rural links not severed due to urban migration/Income generation activities (especially for women)/Minimum wages as related to the cost of a basic food basket/% of income spent on food/Household expenditure patterns;
4. Breast feeding promotion/Emphasis on improving weaning practices/Role of women in health and nutrition/Women workload and time constraints/Daycaring/Strong kinship (role of extended families)/Child caring capacity/New emphasis on the consumption of native foods;
5. Emphasis on education/Literacy/Gains and needs in manpower training in health and nutrition;
6. Gains and needs in EPI, FP and PHC coverage overall;
7. Installation or strengthening of Early Warning Systems;
b. Challenges
8. Negative social effects of Structural Adjustment Programs and palliative measures taken;
9. Special problems: Urban malnutrition/Street children/AIDS/Refugees/Maternal mortality.
Other challenges in need of attention most often highlighted by the 31 country papers, but not presented in a panel here are the following:
Post-harvest food losses/Salt iodization/Vit.A and Iron supplementation and fortification schemes/Food quality and safety control measures/Provision of clean water/Environmental sanitation/Antenatal care coverage/Safe deliveries/Diarrheal diseases and ARIs/Malaria/Intestinal parasites/Weaning foods.
PANEL No. 1: The empowerment factor
Participation/Emerging grassroot organizations involvement/Adoption of a new development paradigm in which people are more considered as actors and their empowerment plays a growing and decisive role.
1. THE EMPOWERMENT FACTOR
Eighteen of the 31 country papers reviewed (Lesotho, Malawi, Niger, Nigeria, Sierra Leone and Tanzania prominently so) explicitly mention that they see the need to effectively open the process of decision-making to the people.
The battle against underdevelopment will be won by many little people doing many little things in many little places. Empowerment means something more than people following instructions or being able to answer narrow questions. To be empowered is for people to increase their capacity to define, analyze and act on their own problems. In the past, participation has actually been more an exercise of integration than of incorporation of people. Incorporation tries to make people partners in the system making them benefit from the venture(s) undertaken. This has mostly not been the case so far. The issue has rather been finding ways of integrating people into a preconceived development process. People are where they are today, not because they have been genuinely incorporated into the process as such, but because they have been integrated into the existing social formation in the country. Genuine participation gives people a transformative rather than a fatalistic outlook toward the world. The process of genuine participation thus calls for translating change into acceptance. Further, empowerment is about creating new community for a and meeting grounds where grievances motivate and spark effective, powerful action. Felt needs should not have to wait for an opportunity. They are to create new opportunities. In other words, rights have to be taken. They are not given. Simply put, without participation, people are unable to consolidate moral outrage into effective power which is the key to the type of changes needed. Without some modicum of effective power and the ability to use it in an organized fashion, participation remains mere window-dressing. It is the silence of powerlessness that keeps the needs and desires of the poor (especially rural) from being part of national political agendas. Only through people’s empowerment do governments feel compelled to pay more attention to the claims of the numerically strong but economically weak. Therefore, only with a stronger de-facto control by the people comes change, allowing them to practice a much more adapted, responsive and accountable form of democracy. Empowerment is thus about nurturing the spontaneous local sparks of awareness into concrete actions. The dialectical unity of knowledge and action must be an essential aspect of the empowerment process. Fundamental change is simply not possible without some conflict with the powers-that-be. A working coalition of people has to amass independent power and bring together organization, leadership, ideas and a plan. To be relevant, participation has to start from the people’s viewpoint, from their accumulated experience and their specific present economy. These days, popular demands need to be accompanied by concrete proposals (“the problem must be solved in the following way:…”). The people, effectively organized, are not only to place vague demands, but offer and fight for concrete, viable alternatives. The poor have been forced to challenge the context of existing policies so as to influence key actors and institutions at all needed levels. The organization of grassroots groups as pressure groups has to go through an incremental development process – developing trust, building a shared vision and, finally, establishing a strategy.
In the coming Decade, donors need to actively encourage and foster (if not demand) these emerging grassroot efforts and meeting grounds where grievances are no longer sources of defeat, but motivate effective, power-backed action; where people can learn the practices of work in common. Genuine participation has to make people feel affirmed; it has to help them deal with their real pains. People have to be invited to participate in direct actions and thus practice grassroots democracy. At the root of strong, genuine participatory democracy is the need to set up legal entities that define people’s rights more bindingly, so as to transform millions of inhabitants into millions of equally sharing citizens. The future of this citizen’s participation in development lies in the hands of ordinary wo/men, in their level of consciousness about what rules their lives, in their comprehension of the multidimensional and interrelated nature of the development problem(s), in their courage, their capacity to overcome fear and insecurity, their willingness to come out of their various closets and to collectively create the conditions and the compulsion necessary to change their surrounding reality.
Forceful donor support (moral and in-kind) can indeed help making this challenge of the 90s a real window of opportunity.
PANEL No. 2: A national commitment to health and nutrition: Does everything start with a sound causal analysis?
Policy reviews or new policies called for in which health and nutrition issues pertaining vulnerable groups become national priorities/Political commitment expressed towards health and nutrition activities /Nutrition as an ethical and human rights issue/Sound causality analysis carried out.
2. A NATIONAL COMMITMENT TO HEALTH AND NUTRITION: DOES EVERYTHING START WITH A SOUND CAUSAL ANALYSIS?
Twenty six of the 31 country papers reviewed (Malawi, Niger and Tanzania prominently so) mention having used the opportunity of getting prepared for the ICN and for the challenges of the coming Decade to either having reviewed their existing health and, nutrition policies or to having started the process of drafting one. Only 6 countries (Algeria and Tanzania prominently so) highlighted that – health and nutrition being considered basic rights – high-level political commitment had already been expressed by their governments to back the ICN plans for the next Decade. Unfortunately, only 6 countries (and only Tanzania prominently so) based the bulk of their analyses and recommendations on an explicit conceptual framework depicting the causality of ill – health and malnutrition.
Health and nutrition issues have to be part of national development policies. Much lip service has been paid to this concept. But lip service is not enough; nor is it enough to just incorporate such health and nutrition components in national policies. Action plans have to actually fund and carry out these proposed components.
Here is a matter of principle where, first and foremost, a commitment beyond lip service has to be obtained from national authorities. The donor community should and can act as an ombudsman on this issue: it is a prospective, long-term task. Through their access to high-level decision-making levels, all donors can take advantage of the window of opportunity created by so many countries having already embarked in setting national agendas for action. Donors are requested to concertedly help national technical health and nutrition teams to secure this type of government commitment. The justification for such lobbying should be based on a purely ethical basis and the issue should be made a human rights issue.
More comprehensive and relevant causal analyses to justify the selection at priorities in sectoral health and nutrition plans need to be made a requirement. The ICN Secretariat has already adopted and recommended one such analysis which was clearly only used by a few countries, UNICEF has started promoting the use of its conceptual framework with the training of their own African field officers and members of African NGOs. In the next year, these officers will share this methodological approach to causal analysis with their African national counterparts and future rewrites of national health and nutrition plans will have to incorporate more systematic causal analyses that will give better guidance to national plans or action. There in lies the challenge. Donors are called upon to demand that national plans and, more specifically, proposals submitted to them should have an explicit causal analysis to justify the actions proposed for their funding.
PANEL No. 3 : Breaking out of the poverty cycle
Links between income and health-nutritional status highlighted as crucial/Urban-rural links not severed due to urban migration/Income generation activities (especially for women)/Minimum wages as related to the cost of a basic food basket/% of income spent on food/Household expenditure patterns.
3. BREAKING OUT OF THE POVERTY CYCLE
Twenty five of the 31 country papers reviewed (Burundi, Malawi, Morocco, Namibia, Niger, Nigeria and Tanzania prominently so) made unequivocal pleas for the improvement of household incomes as a prerequisite to improve the health and nutritional status of the poor.
The donor community (and others as well) often overlooks the fact that the poor already possess the basic Knowledge that many a health and nutrition program attempts to impart. But, when families live in dire poverty, merely eking out an existence, mothers cannot implement many of these recommended practices. Once the household income increases, and becomes available to the mother, it makes more sense for her to fallow these messages. Despite it being their legitimate entitlement, the poor have seldom attained the power necessary to demand the share of national resources that would be compatible with guaranteeing them minimum incomes commensurate with decent standards of living, of health and nutrition. With an increase in income (especially if maternal), a direct positive effect on children’s health and nutritional status can be expected; also, women’s labor will decrease as their income increases. Ergo, income for the poor is perhaps the best guarantee for their health end nutritional well being. Given the prevailing situation in Africa, credit is to be considered a fundamental human right – and the most important one of them all – because, most probably, only with access to credit can the poorest even conceive having year- round access to food, health, shelter, clothing, education and the rights which follow. For many donors, popular credit schemes are virgin territory. In the Decade of the African Child, no donor should overlook this stupendous window of opportunity documented, among others, by the Grameen Bank, the world Bank and the ACC/SCN.
Galloping urbanization has brought with it special income/ entitlements problems and challenges. The rather unique links kept by African urban migrant families with their villages of origin often makes the difference between making it or not making it in the cities marginal slums that house them. These links are positive and deserve some creative strengthening, because pretending that urban migration will cease or that urban employment opportunities will improve during the Decade is simply an illusion. In the urban setting, employment and minimum wages, and the adequation of the latter to the changing cost of a basic food basket ought to be more at the center of our worries. Family budgets consistently over-stretch the already swollen food item to levels where, invariably, malnutrition of the most vulnerable family members is the weakest link in the chain that can give. Nutrition surveillance activities – so popular with donors – have a lot to gain when made a module of household expenditure surveys (as opposed to clinic-based surveillance activities). The anthropometric/household expenditure data duly correlated have an immensely greater advocacy power when used to protect the right to food of the African Urban Child
In the 1990s, pertinent donors have a responsibility to review their support to ongoing or new nutrition surveillance activities so as to adequate them to the new guidelines UNICEF, WHO and FAO have recently developed.
PANEL No. 4 : An enhanced role for the caring of children
Breast feeding promotion/Emphasis on improving weaning practices/Role of women in health and nutrition/Women’s workload and time constraints/Daycare/Strong kinship (role of extended families)/Child caring capacity/New emphasis on the consumption of native foods.
4. AN ENHANCED ROLE FOR THE CARING OF CHILDREN
Nineteen of the 31 country papers reviewed (Congo, Morocco, Namibia, Nigeria and Sierra Leone prominently so) retained strong wording In their plans to be applied during the Decade for the promotion of breastfeeding. Seventeen countries (Malawi, Sierra Leone and Tanzania prominently so) forcefully highlighted the need to focus more on helping women better assume their crucial role in preserving the health and nutrition of their off springs. Nine countries (Namibia, Nigeria and Tanzania prominently so) depicted the African extended family system as an asset to build-on to improve the caring for children while only 3 countries (Benin, Sierra Leone and Zaire) thought more use of traditional, native foods should be made in the battle against malnutrition.
It is by now clear that, in some circumstances, even in Africa, household food insecurity is not the main constraint to good health and nutrition of children in the family. The caring dimension in the prevention of ill-health and malnutrition has been rightly highlighted – both in the presence or absence of household food insecurity – as an area were much can be improved in the years to come.
In Africa, breastfeeding is fortunately still the rule, being practiced at least during a good part of the first year of life. But there is little reason to believe that the continent will be spared the move away from breastfeeding that comes with modernization. For this reason, plus the still burning need of intervening to assure safe and timely weaning practices, donor help should continue to be channeled, in part, to this priority promotive activity. Not doing it, risks shifting the ages of malnutrition downwards with catastrophic consequences on child survival and child development.
The role of mothers in caring for their off springs is seriously eroded by time-consuming daily chores that keep them away from their young children, as well as by their level of understanding of child-care instructions received. Not surprisingly, malnutrition of underfives is the outcome. Also in this domain, donors will find tapped or untapped windows of opportunity for contributing to ongoing efforts benefiting the African Child: from literacy programs for women and girls, to the training of 10-15 year-old girls on child-care practices, to the running of daycare facilities, to educational campaigns geared at promoting FADU(#) feeding behaviors, to the availing to mothers appropriate weaning foods. Simply put, the message is clear: “Love is not enough” for successful child rearing!
Finally, the resurrection of a number of native African foods – whose consumption has been abandoned over the years for a host of “modern”, often imported foods – is indeed another area deserving donor investment, especially in close collaboration with communities directly.
NGOs can and should more often be brought in to become partners in boosting all these activities. Donor inputs can be crucial in making these partnerships flourish this Decade.
(#): F: feeding frequency; A: amount to be fed; D: nutrient density; U: nutrient utilization.
PANEL No. 5 : The right to know
Emphasis on education/Literacy/Gains and needs in manpower training in health and nutrition;
5. THE RIGHT TO KNOW
Twenty one of the 31 country papers reviewed (Ghana and Morocco prominently so) put special emphasis on the need of expanding literacy campaigns and primary school enrolment – incorporating health and nutrition components into the respective curricula – as an important tool in the achievement of minimum development goals. Twenty six countries (Congo, Cote D’Ivoire, Malawi, Morocco, Namibia, Nigeria, Rwanda, Sierra Leone and Tanzania prominently so) recognized their urgent needs in the area of manpower (training in health and nutrition and planned for expansion of their existing training capabilities.
The last two decades have witnessed a veritable educational revolution in Africa. Efforts centered mostly, but not only, around the goal of attaining universal primary education (enrolments have soared) and around boosting adult literacy. Attempts were made to be gender-neutral in this approach, but success in this was and has been limited. The present and future payoffs of what has been achieved are immense, but there are still significant quantitative and qualitative gaps to be filled in the coming Decade. Resources invested in this continentwide quantum leap have mostly been the countries own, and that shows a formidable commitment not to be underestimated. On the other hand, by now, families have internalized the value of education (not necessarily gender-neutrally) and this fact closes the educational supply-demand loop that has to be looked at as a powerful window of opportunity for donors to offer a helping hand.
The other challenge cum window of opportunity here pertains to the growing need and demand for quality technical education and the on-the-job training of manpower, specifically in health and nutrition in the case we are considering, both in the government and non-government sectors. This training is not a one-shot deal (nor is it cheap); it requires periodic, decentralized updating. A fair amount of it is going on right now and, so far, this training has significantly depended (and will continue to in the future) on donor technical and financial inputs. Mind that a sizeable core of African nationals do have the needed skills to be in charge of this training. When this is the case, donors have to let go of top-down approaches in this area. Africa has come of age and needs partnerships; not preconceived packages; in exchange, it is willing to offer professionalism and accountability.
Degree training in the North has repeatedly proven to be inadequate for Africans being basically ill-suited for the African context. During the coming Decade, national, or better, regional African institutions have to be strengthened to take over this training task. Here is a call to donors for entering institution-building partnerships and for providing scholarship funds.
PANEL No. 6 : The population/PHC/nutrition link
Gains and needs in EPI, FP and PHC coverage overall.
6. THE POPULATION/PHC/NUTRITION LINK
All but 2 of the 31 country papers reviewed (Algeria, Burundi, Comoros, Congo, Cote D’Ivoire, Ghana, Guinea, Nigeria, Rwanda, Sierra Leone and Tanzania prominently so) made it explicit that gains in PHC are indispensable to improve the nutritional status of vulnerable groups; the EPI, FP and CDD programs were highlighted as being crucial although other components of PHC. (e.g. water and sanitation) were also prominently mentioned.
What the above response by the African countries about the role of PHC shows is that the window of opportunity opened in Alma Ata in 1978 is still wide open and has definitely been internalized by countries. At least conceptually. This overwhelming response (29 countries) is not matched by their spontaneous reporting on the issue of participation/empowerment (18 countries) which definitely is part and parcel of PHC. (See Panel No. 1) The point that this brings up is that there still prevails the deception that PHC can just be applied as a package of additive technical interventions. And donors may be partly to blame for this.
That the nutritional status of communities is dependent on access to and utilization of PHC services is no news, and nothing is wrong with concerted EPI, FP and CDD efforts and with continued donor support in these and other areas of PHC. But, very much in the (forgotten or conveniently overlooked) spirit of Alma Ata, these national programs are in dire need of decentralization and democratization; they need to be de-verticalized (or horizontalized) to blend them in with other PHC components at the local level so as to primarily open them up to community participation and also to run them in a more coordinated manner from the local level, more effectively sharing training, logistical support and other resources. Donor leverage along these lines can make a difference and should thus be used in the years to come.
PANEL No. 7 : Never be sorry to be too late
Installation or strengthening of Early Warning Systems.
7. NEVER TO BE SORRY TO BE TOO LATE
Fourteen of the 31 country papers reviewed state that disaster Early Warning Systems are either in place or are in the process of being strengthened or installed.
In Africa, cycles in the weather (mainly droughts) seem to have spans of around ten years. It is, therefore, foreseeable that in the Decade of the African Child at least one such drought will hit some part of the continent. Other natural disasters are even less predictable although they may be geographically more circumscribed. Early warning systems will (and have) play(ed) a vital role in safeguarding the wellbeing of sometimes large segments of the population at risk of acute household food insecurity. As it happens, the acuteness is actually not so acute; and that is what early warning is all about. Human suffering of proportions can be avoided not only by taking early measures to overcome the emergency, but also so importantly by providing the means for the reinsertion of the affected population back into normal life in a way that can prevent some of the evil, should disaster strike again. Governments, NGOs and donors have learned this lesson and are moving from purely relief operations to “early warning/relief/ reinsertion/sustainable rehabilitation operations”. Since most of this will still be needed for quite a few years to come, donors are called upon to build on what has already been developed in this area by generously contributing needed resources.
As pertains to man-made disasters leading to the same acute household food insecurity, hunger and death situations, early warning systems should not be written off lightly. The OAU is currently making inroads in setting up continental watchdog operations that could recommend the deployment of an African peace-keeping force when needed. Not unlike the UN peace-keeping forces, this development deserves being considered with an open attitude by the international community. The role that the main bilateral donor countries can play in aborting destabilizing national or regional conflicts should not be discounted either. The human rights leverage can be forcefully applied in contingent bilateral diplomacy, not as an early warning, but as a preemptive move to prevent violent man made disasters.
PANEL No. 8 : Pressures imposed to address the economy: Do the people matter?
Negative (…)
8. PRESSURES IMPOSED TO REDRESS THE ECONOMY: DO THE PEOPLE MATTER?
A surprising 21 of the 31 country papers reviewed (Nigeria prominently so) bitterly complain about the negative social effects of Structural Adjustment Programs (SAPs) imposed by the IMF: mostly on health and nutrition. Only a few of these countries have received funds to specifically embank on some kind of compensatory social program to revert these effects.
To begin with, less than half of the 21 country papers admit that, as intended, the bitter pills of Structural Adjustment have at least succeeded in redressing key declining economic indicators. The main macroeconomic imbalances that rule the relationship between the North and the South remained heavily skewed against the South during the 80s, so this IMF packaged shock therapy was actually doomed to succeed only very partially. Although there is no way of saying what the consequences on health and nutrition would have been without the SAPs in those countries, one can say that its measures were prospective, were often planned well ahead, were implemented with the knowledge of their effects in other countries in the continent, and still no palliative measures (the human face of SAPs) were designed and implemented concomitantly – with only counted exceptions. Now, a considerable part of the damage has already been done (will we be left with a generation of “survivors of SAPs”…?). But, of course, on social issues, forceful palliative measures are better started late than never.
This is indeed a big moral and logistic challenge to, Northern donors. There is a big catch-up task to be undertaken to revert the effects of the “lost decade of the 80s” and to make the decade of the 90s the winning Decade of the African Child. The African country papers prepared for the ICN of December 1992 are a good tool to start working on concrete, bankable projects rooted in the existing positive system imported. The spectrum of choices for projects that donors can help plan and finance can be found in those same papers, but also in the nine Panels here presented.
PANEL No. 9 : Other factors to reckon with in the 90s
Special problems: Urban malnutrition/Street children/AIDS/Refugees/Maternal mortality.
9. OTHER FACTORS TO RECKON WITH IN THE 90s
Nineteen of the 31 country papers reviewed (Congo, Cote D’Ivoire, Ghana, Guinea, Malawi and Rwanda prominently so) made the point that they foresee the need to tackle new special challenges during the coming Decade. Such challenges include either of, or combinations of, AIDS, urban malnutrition, street children high maternal mortality and the problems of caring for refugees.
What do African rates of urban malnutrition, street children, AIDS and maternal mortality have in common? The answer is that, in most cases, they have not reached their peak yet; one can only hope that the problem of refugees (and internally displaced people) has. As if all the other challenges depicted in the will have to reckon with these modern problems as well. In some countries, some of these problems are rather new or unpredictable; in others, they have been creeping up slowly to each intolerable proportions.
Urban malnutrition has already become a bigger public health problem than rural malnutrition in a few countries in the continent and is growing in relative importance in all others, as is the problem of street children. The latter is not unrelated to the continentwide AIDS problem (through its orphans); the AIDS problem surely needs no further elaboration in this Panel. Maternal mortality is the silent tragedy of Africa (and quite a massive one at that) and there is clearly more that can be done to alleviate it. In the case of refugees, not only do numbers matter, but there has been growing concern about the improper care they are getting, from the inertia seen in starting relief operations to the calculation and , further putting together of their food rations (claimed to be unbalanced). Recipient countries have often been literally overwhelmed by the influx of refugees to the point of being unable to even cope with the problems of their own people.
Neither governments nor NGOs nor donors can be passive bystanders when facing these burning issues of the 1990s. Rather, more than ever, concerted and aggressive efforts are needed to tackle each of them frontally. Carefully targeted international help can go a long way in helping these countries mobilize their own resources to live up to these challenges.
Claudio Schuftan
Ho Chi Minh City, Vietnam