Testimony before the

House Committee on Foreign Affairs’

Subcommittee on Africa and Global Health

Child Survival Hearing

Child Survival: The Unfinished Agenda to Reduce Global Child Mortality

March 13, 2008

Thank you Chairman Payne, Ranking Member Smith and members of the Committee for calling for this hearing on child survival. Thank you, too, to Senator Frist for your interest and commitment to the children of the world.

My name is Dr. Anne Peterson, and I am here today to represent the perspective of faith-based organizations. I am the Director for the Global Health Centre at World Vision, a Christian humanitarian organization operational in nearly 100 countries. World Vision provides hope and assistance to millions by joining with local communities to tackle poverty and injustice, ensuring vulnerable children and families reach their full potential.

I respectfully request to submit my longer written testimony for the record.

Today we have an incredible opportunity to keep global promises, convey the compassion of the American people, provide global leadership to help others, and strengthen U.S. relationships with other countries.

You have heard information about the scope of the problem and the interventions that could save two-thirds of the 10 million children who fall ill and die each year. As Congress considers the Child Survival Act, I hope to shed light on four critical areas on which the U.S. should focus to ensure children are rescued from preventable diseases and death. In order to help save some of the more than 10 million children who die each year, the U.S. should (1) increase support for prevention activities aimed at the household and community level, (2) engage directly with local communities, (3) focus attention on children in conflict zones and in underserved areas, and (4) support the role faith-based and community-based organizations fill in addressing this tragedy.

What should be the focus of a United States Government child health strategy?

The U.S. Government has long supported effective programs in child and maternal health with interventions that have been confirmed in global medical literature and the public policy arena. The US government should continue to support such activities, but incorporate within this strategy an increased focus on preventive interventions at the household and community level which can save the most number of lives. The Child Survival Act highlights this approach.

I first understood the need for this approach while visiting a small mission hospital in Zaire, now the Democratic Republic of Congo, as a fourth-year medical student. The pediatric ward was full of children, all with measles. I was appalled at how many died of what in the U.S. was a minor and vanishing childhood infection. A few weeks later, I went on an outreach mission into some of the local villages. One child there changed my life. He was about 18 months old, but only the size of a seven month old. He had the red hair and stunting of chronic malnutrition. He had an enlarged spleen and anemia from chronic malaria. He had polio paralysis in both legs and open infected sores from scabies. In the midst of the measles epidemic, his chances of survival were abysmally low. I then realized his problem was the same as that faced by those small children under medical care in the hospital – dying from something that could be prevented with minimal cost. If he had lived, serious malnutrition at his young age would have compromised his intellectual capacity, and the polio would have left him paralyzed for life. So it is for the millions of children who die and for the millions more who survive with less than their God-given potential.

Child survival goes far beyond providing medication for an illness – it means getting serious about the things that keep people healthy. It would be a mistake to think that focusing solely on improving clinical solutions will have the greatest impact on the diseases and illnesses that plague so many young children. For example, Oral Rehydration Salts provided to children with diarrhea are a good thing, yet they fail to address the underlying cause of the diarrhea which can often be traced to the dirty drinking water they consumed in the first place. The inexpensive household interventions that could provide safe drinking water right to the mouths of children aren’t provided, and diarrhea often ensues. Other issues such as malnutrition have long been neglected despite knowledge that malnutrition contributes to more than 50 percent of child deaths. Lack of food is not the only problem, though agricultural productivity and poverty play a role. Poor diet, seasonal food insecurity and closely spaced births all contribute to malnutrition. Diseases like diarrhea and malaria take an additional toll.

World Vision is actively involved in addressing the primary underlying causes of child morbidity and mortality across the globe. Our Micah Project, working in five countries in Africa, reached 2.7 million direct beneficiaries and reduced malnutrition by up to 30 percent within 3 years through diet diversification, disease prevention (such as distributing bed-nets and Oral Rehydration Salts), enhancement of food security and education of parents. Similarly, our community-based therapeutic care has moved the emergency treatment of acutely malnourished children from lengthy, expensive inpatient care to community-centered, home-based interventions using a ready-to-eat food, “Plumpy’nut.” This approach has shown better results for more children over the course of eight weeks than the previous inpatient programs, at a fraction of the cost. Both programs are being replicated in additional countries in Africa and Asia.

Like us, parents everywhere want their children to stay healthy and grow up to their full potential. The U.S. should increase support for efforts that help families realize this right using proven, cost-effective interventions that prevent disease.

Where should the U.S Government focus this work?

You will note from the story I shared earlier that by the time a sick child reaches a clinic it is often too late to undo the harm. Most disease and death occur not at health-care facilities, but at home, and can be prevented there. The Lancet series referred to in the Child Survival Act recommends a package of key interventions. Most of these can be implemented in communities and households, with the exception of simple clinic-based interventions like safe birthing and delivery.

There is considerable global dialogue about the changes needed in policies to address shortfalls in human capacity (too few doctors and nurses) and overburdened or weak health systems – both of which are real concerns. However, this focus ignores the “whole health system” which includes civil society and community level efforts. To truly improve the lives of children, decrease child and maternal mortality, and achieve the Millennium Development Goals, a comprehensive package of interventions to prevent childhood illness and death must be implemented at scale at the community level where disease occurs. Community level perspective and participation helps improve outcomes and avoid what are currently missed opportunities by ensuring better health integration and greater synergy with other sectors such as economic, agricultural and educational development. By focusing at this level, there is greater assurance that child deaths will not only be reduced, but that a healthy environment will ensue where children and families will be able to experience life in all its fullness.

Who most needs our assistance?

UNICEF and the World Health Organization have identified countries with the worst health indicators. Yet even in countries with better indicators, disparities and inequities are growing. As we seek to finish the “unfinished agenda,” we will need to pay increasing attention to the hardest to reach – the poorest, the disenfranchised, the homeless, and those in conflict zones. These are the children and families who live in inaccessible valleys, are caught in deep poverty, are among neglected tribal groups, are disenfranchised or are caught in the cross-fire of conflict zones.

We know that for almost every health indicator or intervention, the poor do worse than the rich and have less access to preventive services or health care. The places with the worst health indicators – those furthest from achieving most of the Millennium Development Goals – are most often war-torn areas. Increasingly, millions of women and children are living in these disaster and conflict zones. They need protection from the harm of conflict, but they also need and have the right to the same things as children everywhere - a healthy diet, clean drinking water, a bed net to keep away mosquito-borne diseases, immunizations, and access to clinical care.

Where there is conflict, it almost always means that the government cannot fulfill its mandate to care for its own people. However, many times NGOs are there, from Medicins Sans Frontieres, to Senator Frist’s work with Samaritan’s Purse in South Sudan, to World Vision in Afghanistan. At risk to themselves and their families, staff from NGOs and faith-based organizations are often the first to respond in the hardest places and the last to leave. When I visited Afghanistan with USAID in 2004, two local NGO staff had been killed the previous week because of the association with the U.S. government. Yet even as their peers grieved, the head of their organization told me he and his staff were determined to continue bringing hope to their people. And that hope was being realized. Visiting a small clinic outside the town of Herat, Muslim elders thanked USAID saying, “Our women no longer die in childbirth and our children do not get sick and die. This is the ‘Peace Dividend.’”

How can we assure the most needy populations are reached? There must be careful measurement of what is happening and solid data to identify systematic inequities. This data will allow better, more purposeful targeting of programs to assist the poorest, the forgotten, and those in harm’s way. The links between the work of the Office of Foreign Disaster Assistance and the Child Survival and Health Programs development portfolio should be strengthened by USAID, and the work of U.S. government partners should be geared toward reaching the most needy.

With whom should the U.S. Government be working?

There are vibrant examples of the role Governments play in aiding their own citizens to prevent childhood illness and death, such as Ethiopia, which has been training 20,000 health outreach workers. However, few Ministries of Health are able to reach deeply into the communities and provide a high level of coverage of preventive interventions. In order to achieve success and increase coverage, there must be a partnership between civil society and government. Faith-based and community-based organizations help provide this crucial link.

[E1] We are entering a new era where the divide between government and civil society in development work is being overcome. I have recently seen a new and more intensive level of cooperation between NGOs and governments and a strengthening of public-private partnerships to address these global health challenges. A component of World Vision’s health strategy is to facilitate access to quality care through partnerships – mainly with Ministries of Health. These partnerships have raised awareness of immunization’s benefits and ensured that vaccines are available for remote communities where the needs are often greatest. Differences in culture, organizational priority, and even historical competition for resources are now being overcome and synergistic cooperation is now benefiting more children.

Faith-based and community-based organizations are essential partners in the fight to reduce child mortality worldwide and are often the key to mobilizing communities to achieve these ends. Ensuring progress on the Millennium Development Goal of reducing mortality for children under five by two-thirds by 2015 will require the networks, support, trust, and influence that only faith-based and community-based organizations can provide.

According to the World Health Organization, faith-based and community-based organizations account for as much as 30% to 70% of all health care in sub-Saharan Africa, and are an important component of health care delivery throughout the world. Organizations like World Vision are often deeply embedded in the community and have spent decades providing care, support, treatment and prevention at the local level, in many cases where no other provider of care exists. The value of these organizations rests in the influence and support they have in the local community, enabling better mobilization of resources, people and services. They also have built far-reaching networks. Many faith-based organizations have as their specific mandate to reach the poor and intervene when others suffer from poverty, sickness, disease, and death.

Faith-based and community-based organizations also contribute to more sustainable solutions and help reduce dependence on foreign aid. Faith-based institutions, churches, and community groups which have existed for many years empower parents and community elders, ensuring the impact lasts beyond the life of a grant or time-bound funding stream. Twenty-five years ago I served with Mission Moving Mountains, a small mission organization in Kenya working with the local Anglican Church conducting community-based health programs. In three years, the work expanded from zero to 29 villages. A small USAID grant of $25,000, alongside other funding, facilitated this successful growth. More importantly, I went back recently and found that the church had continued to expand the work, obtaining funding from a variety of sources. They were still successfully reaching out to new generations of children 20 years after USAID funding had ceased.

Americans, your constituents, show their care for children by their personal contributions to their favorite charities, many of which, like World Vision, have seen remarkable growth in recent years. There are strong trends among many NGOs, including faith-based organizations, to use best practices and achieve measurable results – something in which both public and private donors increasingly seek to invest. Faith-based and community organizations are better able than ever to deliver results based on clear strategies and strong accountability.

Conclusion

If we as a nation are serious about achieving the Millennium Development Goals, then we will support U.S. leadership on child survival and ensure passage of Child Survival Act. Given the inexpensive, proven solutions that exist, the reduction of child morbidity and mortality by two-thirds represents one of the easiest goals to achieve.

However, funding alone will be insufficient. Efforts must be focused on those interventions that make the most difference, targeted where the need is greatest, directed to those who need the most help, and implemented in conjunction with trusted partners who have a track record of success.

Please make this your personal issue. As parents yourselves, as representatives of all the parents in your constituencies, and for the children who lack other representatives, I encourage you to tenaciously pursue justice, health, and hope on their behalf.

I urge you to pass the Child Survival Act. It is the right thing to do for the children. It is good politics, building relationships across the world and with constituencies at home. The cost is small compared with much of what you are asked to fund, yet can show such gain in lives, in hope and in restored relationships. This truly is a win–win situation. Please support this bill and champion the funding to make it a success.