Our blog post yesterday focused on the close links between population, women and climate change in developing countries, as documented in UNFPA’s new State of the World Population 2009 report released on Wednesday.

Today I spent the better part of the day in the White House focusing on a domestic dimension of that same phenomenon — the public health benefits of clean energy reform in the U.S. The Obama Administration — through Secretary of Health & Human Services Kathleen Sebelius, Environmental Protection Agency Administrator Lisa Jackson and other senior officials of both departments — made a strong case for the many health reasons we should care about clean energy, in additional to the many environmental and economic ones we already know about.

Administrator Jackson related to the issue in a very personal way: She talked movingly about her 13-year-old son, who has been asthmatic since infancy and could not always go outside because of air quality (she said that one in 10 American kids suffer from asthma).

The hundred or so people attending the summit had come from all over the country on relatively short notice for something they believed in, and more than a few of them expressed passion, commitment and gratitude that the administration was taking this on. There were business and community leaders, advocates, activists, academics and nonprofit leaders from California, Alabama, Louisiana, Michigan, Minnesota, Massachusetts and many other states.

I saw only one other person there from our world of global health and wondered whether the White House might have invited us by mistake. But it gradually dawned on me that just about everything that was said about how clean energy can improve health in the U.S. also applies to the developing countries we care about at the Global Health Council. Secretary Sebelius raised it once, when she said that global warming was increasing malaria, dengue and salmonella.

I wondered whether this new partnership to promote the benefits of clean energy in the U.S. would manifest itself in any way in the Global Health Initiative proposed by President Obama in May. I hope so because just like the most vulnerable Americans are hit hardest by climate change, the most vulnerable and poorest people in developing countries are most affected (and, as I found out Wednesday at the UNFPA event, women are particularly vulnerable). These people in the poorest countries in the world probably benefit even more from clean energy than do the poor in the U.S.

The global health community — including the Global Health Council – looks forward to working with the Obama Administration to highlight the public health benefits of clean energy not only in the U.S. but in the developing world as well.

On Nov. 25, The Lancet will publish a major international study on the public health impacts of reducing greenhouse gas emissions, the first major study of its type.

WASHINGTON — “Family planning, reproductive health care and gender relations could influence the future course of climate change and affect how humanity adapts to rising seas, worsening storms and severe droughts.” I bet you haven’t heard much about that in all of the recent discourse on global warming and climate change.

And those attending the upcoming U.N. Climate Change Conference in Copenhagen, Denmark,  are unlikely to hear much about it either. There has been almost nothing on population in all the communications leading up to Copenhagen. And we all know why: people don’t like to discuss issues of family planning and reproductive health and run away from confronting them. The reasons are many — cultural hang-ups, religion, politics and any other reasons people can find.

My my first sentence above comes directly out of the UNFPA’s “State of the World’s Population 2009“, released yesterday. I attended the Washington launch of the report at the National Press Club. The focus on the report this year is on the links between women, population and climate. Although there is little data on these links, the data that we do have clearly shows that women contribute less to climate change then men while they are most affected by it. Despite that, women have been largely overlooked in the debate about how to address problems of rising seas, droughts, melting glaciers and extreme weather.

Robert Engelman of the Worldwatch Institute, the principal author of the report, said that the new report does not call for new spending. “What it does do is remind governments of commitments they have already made at the International Conference on Population and Development in 1994 and the Millennium Development Goals and calls on them to honor those commitments in order to reach more of the 200 million people in the world, virtually all of them poor, who still have an unmet need for family planning,” Engelman said.

Former U.S. Sen. Tim Wirth, the president of the U.N. Foundation, talked about receiving a parka in the mail recently sent by “global warming doubters.” He asked everyone at the National Press Club event to turn to a graph on page 11 of the report that shows the “Ten Warmest Years Between 1880 and 2008″ – based on data from the Worldwatch Institute. Those warmest years, in order, are 2005, 1998, 2002, 2003, 2006, 2007, 2004, 2001, 2008 and 1997. So, I wonder on what basis the parka gift givers believe that the climate is not getting warmer.

One of the main points of the report is that if women are empowered to control their own reproductive lives, their environment and in other ways, they could launch a genuinely effective long-term global strategy to deal with climate change and play a major role in starting to reverse the warming of the Earth’s atmosphere.

Global Health Council Research Associate Rachel Hampton is at the International Conference on Family Planning in Kampala, Uganda.This is the second of her posts from the conference.

KAMPALA, Uganda – On my first morning in here, I bought a copy of the Sunday Vision, the sister paper of Uganda’s leading weekly newspaper, New Vision. Local news and politics dominated the content, and it wasn’t until page 11 that I found an article related to health. The article was actually a letter to the editor from a reader concerned about road safety and traffic injuries after the construction of a new local highway. The remainder of the paper only contained four other pieces about health, mostly focusing on diet and nutrition.

Compared with American print media, the amount of health reportage in the Sunday Vision was extremely low. However, this afternoon at the conference I learned that the content of the Sunday Vision might be greater than other sub-Saharan African newspapers.

During the presentation, “Family Planning, Abortion and HIV in Ghanian Print Media: A Content Analysis of the Most Widely Circulated Ghanaian Newspaper Since 1950,” Amos Kankponang Laar, a student at the University of Ghana, examined the coverage of health issues in the Daily Graphic, a newspaper that reaches more than 200,000 people in 10 regions in Ghana every day. Laar used a composite week sampling technique to select 62 editions from a sample of 443 editions (all editions from Jan. 1, 2008, to March 31, 2009) for analysis. Overall, he analyzed 4,690 items, including straight news, features, editorials and letters to the editor. He found that only 4.2 percent (197) of the articles were about health and, of that, less than 1 percent (25) were on reproductive health. Furthermore, this sample of 62 editions contained only 0.09 percent (4) articles on family planning, 0.04 percent (2) on abortion, and 0.4 percent (19) on HIV/AIDS. Nearly all of the health articles were buried in the middle pages of the papers.

Laar’s study showed a lack of reportage of health issues in the Daily Graphic. I cannot say if that is the case for the New Vision or not based solely on my Sunday copy. What I can say is that findings of Laar’s study could potentially indicate a worrying trend. Another issue that I think could perhaps be of concern is the accuracy of reporting. Laar’s study did not analyze the content of the health articles, but I think it would be interesting to see what it is the reporters are writing, and whether or not this stands up to fact. It is not only important that health makes the headlines, but it is equally important that people are getting useful, accurate information about their health.

Global Health Council Research Associate Rachel Hampton is at the International Conference on Family Planning in Kampala, Uganda. This is the first of her posts from the conference.

KAMPALA, Uganda – Family planning is often heralded as one of the top ten health achievements of the 21^st Century. Contraceptives play a major role in this success, and new advancements in contraceptive technologies continue to make family planning more accessible to a broad audience of couples looking to space or delay births.  The first International Conference on Family Planning: Research and Best Practices — sponsored by Johns Hopkins Bloomberg School of Public Health, Makerere University School of Public Health, and the Bill & Melinda Gates Foundation – has brought together more than 1,000 people from all over the world to participate in a three-day long series of technical sessions, roundtables, workshops, and presentations on family planning.

Monday was the first full day of the conference, and the morning started with a presentation from Laneta Dorflinger of Family Health International on research needs for contraceptive technology development. According to Dorflinger, current contraceptives are falling short, and new technologies are needed to meet the needs people in developing countries.

Some modern contraceptives can be difficult to use consistently and correctly and others might have side effects that lead to discontinued use, Dorflinger said. Men and women also have different reproductive needs throughout their lifespan, and need access to a variety of contraceptives to help them plan, space, and limit pregnancies. New technologies are needed to overcome these challenges and help to fulfill the unmet need for family planning. Dorflinger said that these new technologies should be user-independent, reversible, low-cost and broadly available. In addition, they should have minimal or no side effects or positive side effects that actually improve overall health. New products with these qualities could help to reach a new market of potential contraceptive users and recapture men and women who have discontinued use after dissatisfaction with current methods.

Eager to learn more about these new contraceptives, I left Dorflinger’s presentation and headed to a panel on new contraceptive technologies, which included presentations on a new implant, an over-the-counter diaphragm, a year-long ring, and an injectable contraceptive packaged in a one-dose, user-friendly device. According to conference participants, we can expect to see these projects on the world market over the next few years:

Sino-Implant (II): A contraceptive implant manufactured by Shanhai Dahua Pharmaceuticals in China. According to Ruth Merkatz of Population Council, the sino-implant is available at more than 60% less than the price of the other implants available on the market. It is registered in China, Indonesia, Sierra Leone and Kenya. More than 7 million implants have been distributed, and 11 published clinical trials show that this new device is safe and effective. The device will probably cost about $6 to $7. It is not currently seeking U.S. approval but is undergoing the approval process in several other markets.

SILCS Diaphragm: A one-size, easy to use, over-the-counter diaphragm produced by GHC member PATH. This new product eliminates the need for a fitting exam, and women can comfortably insert the device themselves at home with the assistance of written instructions. An effectiveness and safety study of the new diaphragm began in 2008 and is near completion in six sites across the United States. Evidence collected suggests that the majority of women can insert this device safely and position it correctly, suggesting that it will meet the criteria for OTC marketing.

NES/EE Contraceptive Vaginal Ring (CVR): A user-controlled CVR produced by the Population Council. Unlike other CVRs that can only be used for a month, this new CVR can be used for up to 13 cycles or one year, reducing costs and increasing user convenience. The NES/EE CVR is currently undergoing Phase III clincial trials to determine if it is safe and effective, and to assess cycle control, return to fertility and side-effects. Preliminary findings suggest this new device is highly effective in preventing pregnancy and has a safety profile that is similar to other contraceptives. Population Council aims for this contraceptive to hit markets in 2011.

Depo-subQ Provera 104 in the Uniject Device – A technology that packages a familiar injectable contraceptive into a one-use, prefilled injection system. The Uniject device is a “single, prefilled delivery service with subcutaneous needle.” It is basically like a pre-filled syringe that is only good for one use. The proper amount of depo-subQ provera 104 (similar to currently used depo but reformatted to fit the new device) is already loaded into the Uniject device, and can be injected under the skin rather than under the muscle. This new contraceptive technology will help to reduce waste (packaging) and improve safety (one-use needle), and is easier to deliver by nature of the pre-loaded Uniject device.

So, what do these new devices mean to developing countries? Well, many of these new contraceptives are more cost efficient and easier to use than other devices on the market. The SILCS diaphragm and the CVR are both user-controlled contraceptives than can be easily inserted by women and can be used again and again for many months. In addition, many of these new contraceptives could be easily distributed or delivered by community health workers.

The new packaging of depo, for example, makes it feasible for a community health worker to administer it directly. However, there are some caveats that still must be addressed. More information is needed on the removal of the implant, as some women may not come back at the appropriate time after insertion. In addition, the instructions to use the diaphragm are only written in English, which might be problematic for non-English speakers or illiterate populations.

Collectively, these new contraceptives represent a promising new variety of methods, both short-term to long-lasting, to help meet the needs of women during different stages of their reproductive lifespan.

Global Health Council Research Associate Lillian Benjamin is at the 5^th MIM Pan-African Malaria Conference in Nairobi, Kenya. This is the second of her posts from the conference.

NAIROBI, Kenya — While Millennium Development Goal Six (MDG 6) is dedicated to malaria, it is not the only MDG that is impacted by the disease.

MDG 1 - Eradicate extreme poverty: Malaria contributes to approximately 1 percent of gross domestic product (GDP) loss. It also accounts for 40 percent of health spending and 30 percent of household health expenditures in endemic countries.

MDG2 – Achieve universal education: Malaria contributes to absenteeism in Africa. Cognitive damage from cerebral malaria prevents many children from attending schools.

MDG 4- Reduce childhood mortality: Malaria is one of the leading causes of childhood death worldwide.

MDG 5- Improve maternal health: Pregnant women are at increased risk for contracting malaria because of their immunocomprised status. Malaria also contributes to maternal anemia, which can lead to hemorrhage, spontaneous abortion, neonatal death and low-birth weight.

MDG 6- Combat HIV/AIDS, malaria and other diseases: The Global Malaria Action Plan calls for several actionable targets to achieve malaria elimination.

MDG 8- Develop global partnerships: Malaria has benefited from assistance of private-public partnerships to improve access to affordable malaria interventions.

All six of these MDGs are impacted by the malaria burden, but one of the take home messages here at the MIM conference has been the benefit of malaria control on childhood survival, MDG 4. Researchers Rowe and Steketee predict that if malaria mortality is reduced by 50 percent in high transmission areas, all-cause childhood mortality is also likely to decrease (Am. J. Trop. Med. Hyg., 2007; 77: 48–55).  The reduction of all-cause child mortality through malaria control interventions has been demonstrated in several studies,  however one of the most talked about success stories this week was the Bioko experience (Am. J. Trop. Med. Hyg., 2009; 80: 882–888).

Dr.  Immo Kleinschmidt presented the results of the study during the third plenary session of the conference. Bioko, Equatorial Guinea is an island located off the coast in the Gulf of Guinea. The government, along with private industry (Marathon Oil Corporation) and researchers conducted an expanded containment project on the island (the Bioko Island Malaria Control Project).  During the initial phase, a four-year period, the campaign consisted of vector control, indoor residual spraying (IRS) and long-lasting insecticide treated nets (LLIN) intermittent preventive treatment for pregnant women (IPTp) and artemisinin-based combination therapy (ACT).  

The study noted a decrease in malaria-infecting mosquitoes in the area, but the most exciting news was the impact of the intervention on childhood morbidity and mortality. After the intervention, the mean prevalence of malaria infection for children two to five years old dropped from 42 percent to 18 percent, and prevalence of anemia decreased from 15 percent to less than two percent. The all-cause under-5 mortality fell from 152 deaths per 1,000 births to 55 deaths per 1,000.

This study, as well as others, demonstrates the need for an integrated approach to improve health and increase in child survival.

Global Health Council Research Associate Lillian Benjamin is at the 5^th MIM Pan-African Malaria Conference in Nairobi, Kenya. This is the first of her posts from the conference.

NAIROBI, Kenya — Intermittent Preventive Treatment (IPT), the administration of a full course of an antimalarial drug as a therapeutic dose,  has widely been accepted as a  protective measure added to antenatal care for women in malaria endemic countries.  The use of IPT is believed to treat pregnant women from possible malaria infection in hopes of reducing maternal anemia, which can lead to complications during childbirth as well as problems for her fetus. While this practice has been prescribed by the World Health Organization for pregnant women, in the past two days there has been discussion on the use of IPT for other at-risk groups, infants and children.

Intermittent Preventive Treatment for infants (ITPi)  is the delivery of a full course of antimalarials at the time of the Expanded Program for Immunization (EPI) vaccines in the first year of life. Infants would be given IPT at the time of their vaccinations: DTP2 (two months), DTP3 (three months), and measles and yellow fever (nine months). A recent article in the Lancet – Aponte John J, Schellenberg David, Egan Andrea, et al. “Efficacy and safety of intermittent preventive treatment with sulfadoxine-pyrimethamine for malaria in African infants: a pooled analysis of six randomised, placebo-controlled trials.” (2009; 374: 1533–42) –  highlights the findings from a meta-analysis of six different study sites within Africa. The study shows that IPTi with antimalarial medication sulphadoxine-pyrimethamine (SP) was 30.3 percent protective against clinical malaria  during the first year of life.

David Schellenberg also presented results from on the feasibility and community effects of large scale IPTi implementation in southern Tanzania. This study found that when IPTi-SP was administered along with EPI there was a 59 percent reduction in the incidence of clinical malaria and a 50 percent reduction in the incidence of severe anemia in the first year of life.  Alexandra de Sousa discussed the implementation of such programs in six African countries. Her findings showed that even when health care workers were reluctant to participate in the program because of the belief that it would add to an increase in work load, the intervention was welcomed because of the potential benefits.  It also was believed that IPTi would increase EPI adherence as parents welcomed ITPi and wanted their children to participate, thereby coming back for vaccinations.

Dr. Robert Newman, director of the of the Global Malaria Programme, informed the audience that WHO has just released a policy recommendation for ITPi, stating that SP-ITPi, delivered through EPI, is a recommend as an addition to malaria control interventions in countries in Africa when EIR is beyond 10 and parasite resistance to SP is not high. However,  ITPi is not recommended to be given to infants that are being treated for HIV infection.

Research also was presented from the Intermitted Preventative Treatment of Malaria in Children (IPTc) Taskforce. Diallo Didder, Konate Amadou and Dicko Alassane presented research on a trial of IPTc in children, when controlling for use of ITNs (insecticide treated bed nets). The purpose of the study was to see if IPTc adds to the protection provided by ITNs. Researchers enrolled two cohorts of children in Mali and Burkina Faso, the groups were divided by the intervention– administration of IPTc. Researchers were able to control for the use of ITNs by giving all children enrolled in the study ITNs and monitoring the use of ITNs through home visits during the study. The use of ITNss during the study period was more than 90 percent. The children ranged in age from three months to 59 months. They were given three doses of an antimalarial drug in one month during their country’s malaria season. There were no severe adverse effects; however, there was a significant  increase in vomiting and fever for the intervention group.

Although the study has yet to be released and the authors are still reviewing the results, preliminary findings showed that ITPc had a protective effect of 75 percent reduction in clinical malaria, 81 percent reduction in severe malaria, and a 77 percent reduction in hospital admissions. Other presenters examined the logistics and cost effectiveness of the intervention.

Both sessions provided scientific evidence that would merit the uptake of IPT for infants and children, but it is important to note that only ITPi has gone been reviewed by a WHO task force and warranted WHO policy recommendation.  Further research  is still needed on the efficacy of ITPc before it is recommended by the WHO.

The following posting is by Leith Greenslade, Director on the Board of GAVI Alliance Immunize Every Child. The opinions expressed in this posting are solely hers and not necessarily of the Global Health Council.

As welcome as the news was that 3.7 million fewer children are dying before they reach their 5^th birthday, the reality is that the pace of change is nowhere near fast enough to reach Millennium Development Goal 4 by 2015.

One disease holds the key to this goal – pneumonia – and achieving MDG4 will depend on the degree to which pneumonia is singled out for special attention by the global health and donor communities.

This is not just because pneumonia is the No. 1 killer of children, killing some 2 million children under age 5 every year. Fighting pneumonia is the key to MDG4 because we have proven cost-effective interventions to prevent and treat pneumonia. If efforts to get them to the world’s poorest children can be accelerated, millions of child deaths could be averted.

On the prevention side we have some very powerful vaccines.  Alongside the basic pertussis and measles vaccines – which UNICEF acknowledged have been major drivers in the new, lower child mortality rate – there are newer vaccines that specifically target the leading causes of child pneumonia – the pneumococcal and Hib vaccines.

The Lancet published new figures last week that showed that pneumococcus and Hib bacteria cause 1.2 million under-5 child deaths every year, almost all of them in developing countries where vaccines are not available. So successful have the Hib and pneumococcal vaccines been in the developed world that Hib deaths among children are basically nonexistent and pneumococcal disease among children has declined by 77percent, with a 39 percent decline in hospital admissions for pneumonia among children under 2.

In the very few developing countries where these vaccines have been introduced similar results have occurred. In Uganda, four years after the introduction of the Hib vaccine, Hib meningitis fell by 85 percent and by year 5 it dropped to zero.  However, of the 72 poorest countries served by the GAVI Alliance currently just two – Rwanda and the Gambia – routinely offer both Hib and pneumococcal vaccination.

Making sure these two vaccines are routinely available to children in the poorest and most pneumonia-ridden countries in the world is one of the single most important ways to reach MDG4.

On the treatment side, the right antibiotics and oxygen correctly administered by trained health workers can reduce deaths in children who are severely ill with pneumonia. Where this case management approach has been applied in hospitals, deaths have been reduced by up to 40 percent. Making this approach available to children in their communities can yield the same results and is vitally important in those communities which are far from clinics and hospitals and where vaccination is not yet available.

The Global Action Plan for the Prevention and Control of Pneumonia[1] concluded that vaccination and antibiotics, in combination with improved nutrition, control of indoor air pollution, and prevention and management of HIV infection, could reduce child pneumonia deaths by more than 1 million every year.

What could these 1 million-plus deaths mean for MDG4? The difference between success and failure. Even at the new, faster rate of child mortality decline (2.3 percent), MDG 4 will not be reached until 2040.  To achieve MDG4 by 2015 requires an annual rate of decline of 10.5 percent, more than 4 times the current rate!

To put it another way, the child mortality rate target set by MDG4 is 30 deaths per 1,000 live births. In 2015 that could equate to roughly 4.2 million deaths among children under age 5, compared with the 8.8 million under-5 deaths in 2008 reported in September by UNICEF. Between now and 2015 the challenge is to find ways to prevent in the order of 4.6 million child deaths every year.

With pneumonia-fighting interventions potentially contributing 1 million plus, or 25 percent, of the deaths that need to be prevented, it is hard to imagine how MDG4 will be reached without pneumonia being front and center on the global health agenda.

There are welcome signs that this is already starting to happen. The GAVI Alliance, Save the Children, UNICEF and many other organizations have mounted a global advocacy effort to raise awareness about the life-saving potential of pneumonia prevention and treatment.

To date some 70 organizations have joined the Global Coalition against Child Pneumonia. Today, the Coalition will launch the first World Pneumonia Day, with events planned in several cities throughout the world and a Global Pneumonia Summit in New York City.[2]

It remains to be seen whether this Coalition can successfully advocate for greater funding for pneumonia and pave the way for the integrated delivery of prevention and treatment services, particularly in India and Nigeria and the other high pneumonia countries[3], because this is what it will take to significantly reduce child pneumonia mortality.

It also remains to be seen whether the Coalition can engage the broader global health community in the pneumonia challenge. It shouldn’t be too difficult. The interactions between pneumonia and maternal and child health[4], HIV/AIDS[5], malaria[6] and the mounting H1N1[7] threat all make for obvious partnerships.

But it shouldn’t stop with the global health community. As the biggest child health challenge that many developing countries are facing, pneumonia is something that private corporations and donors should clearly be paying attention to. For those companies and donors looking for big impact social investments in the developing world, investing in pneumonia prevention is the best opportunity around.

 Ms. Leith Greenslade is a Director on the Board of GAVI Alliance Immunize Every Child (http://everychild.gavialliance.org). She has served the Australian government in a variety of capacities, including as an advisor to the health minister and deputy prime minister, chief of staff to the shadow minister for social security and the status of women, and economic adviser to leader of the opposition.  Ms. Greenslade holds a Masters in Public Administration from the Harvard Kennedy School and a Masters in Business Administration from the Chinese University of Hong Kong.  

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[1] An initiative of the WHO, UNICEF and the GAVI Alliance funded PneumoADIP and the Hib Initiative, http://whqlibdoc.who.int/publications/2008/9789241596336_eng.pdf
[2] See www.worldpneumoniaday.org for a full list of Coalition members and activities planned for World Pneumonia Day.
[3] Pakistan, Afghanistan, Ethiopia and the Democratic Republic of the Congo have the highest numbers of child pneumonia deaths.
[4] Pneumonia causes up to 20% of deaths in the first month of life.
[5] In southern Africa babies and children with HIV account for about 5% of the under 5 population and 60-80% of child pneumonia deaths.
[6] In many developing countries pneumonia is misdiagnosed and mistreated as malaria.
[7] Studies indicate that a leading cause of death among children with the H1N1 virus was the interaction of the virus with bacterial infections that cause pneumonia.

The following posting is by Sara Friedman and Hourig Babikian. The opinions expressed in the posting are solely theirs and not necessarily that of the Global Health Council.  This is the first of four postings from Friedman and Babikian on the subject of girls in development from a gender perspective.

Earlier this month, we attended the launching of a major report by the Center for Global Development, entitled Start with a Girl: A New Agenda for Global Health. A follow-up to its 2008 publication, Girls Count, the report and panel discussion made a strong case for investing in the health of adolescent girls. “Most girls enter adolescence healthy,” the report says, but then face a myriad of gender-driven pitfalls, trapdoors and health risks that can short-circuit their own development and that of generations of women. Investing in the health of adolescent girls can smooth their entry into adulthood as empowered young women with productive healthy futures and as agents of positive change for coming generations of families, communities and society.

The standing-room-only event (filled by half or more with girls and young women) reflected an explosion of recent interest in the importance of girls (as in women and girls) from a number of public and private spheres – the U.S. State Department, the Clinton Global Initiative, the Nike Foundation, publications such as Girls Count and three installments of PLAN International’s excellent yearly reports, called Because I am a Girl. The United Nations Secretary General has just released a new report on the girl child. Next February also is 15th anniversary review of the Beijing Platform for Action, which includes a separate section on girls.

For those of us who have long been advocating for girls’ rights, this event and the revival of attention to the reality of their situation – and promise – is welcome news. But is this the right message? Adolescent girls represent a critical population and life stage whose needs and promises are largely ignored. But pitfalls and trapdoors and health risks don’t appear at age 10; they are there from birth and before. So using the term “girls” to mean adolescent girls runs the risk of ignoring another critical population and life stage.

If girls are defined by age 10 and older, what then are girls under 10? They are “children” – a stage of life viewed widely and erroneously as gender neutral. But children are not gender neutral, and many girls do not enter adolescence healthy. Women in developing countries, who argued for a life cycle approach to women’s rights, did not suggest it that life cycle started at 10 years of age any more than it started at 18.

There is no shortage of evidence that children are gendered from birth and before. Deeply entrenched son preference in parts of the world has resulted in millions of “missing girls” through sex selection, female infanticide and deaths of young females whose health is often ignored until it is too late.

Ample research shows that gender norms are in place between ages three and five, that by 10, girls themselves already know what society expects of them and that they are second-class citizens. Girls in countries such as Ethiopia and Djibouti are subjected to female genital mutilation between the ages of three and 10, and many girls are already promised in marriage at six or seven or even at birth. Preadolescent girls are still fetching water miles from their homes, and at six and seven are taking care of even younger siblings and ailing relatives. They are facing dangers on the road that delay their entry into school and/or curtail their ability to pay attention, furthering the likelihood of early dropout of school and increased vulnerability to the exploitation and health risks of adolescence. In some countries, young girls face the risk of HIV infection – defiled by men who think that raping virgins will cure or protect them from the virus. In short, as preadolescent girls face unprecedented gender-based violence, we can’t wait until they are adolescents to pay attention.

It was not so long ago that many leaders of the women’s movement in Europe and the U.S. viewed all females under the age of 18 as “children” whose inclusion in the struggle for women’s rights would only dilute their efforts. The growing support for adolescent girls is significant progress, but advocates should not make the same mistake by dismissing their younger sisters (who will one day be adolescents) as children who are safe, protected and healthy – free from the dangers of discrimination – until age 10.  Young or infant female children are already at the bottom of the heap after boys, men and women. Let’s not take away their identity as girls.

Including the word “adolescent” in advocacy for girls leaves space for others to define girls from birth – or before – onward.

Sara Friedman, former managing editor of Global AIDSLink with the Global Health Council, is currently a freelance writer who continues to write on health and development issues with a special emphasis on gender and human rights.

Hourig Babikian, former U.N. representative for Christian Children’s Fund, served at UNICEF in the Office of Public Partnership for more than ten years. She helped to found the NGO Working Group on Girls in 1994 and was a co-coordinator of the group until 2002. Hourig lives in the Philadelphia area where she is currently a management consultant.

WASHINGTON – More than 100 million infants worldwide are now receiving the key immunizations they need to survive before their first birthday every year.

There is great cause for celebration for the lives saved by this remarkable achievement, which was reported to a standing-room only crowd at the National Press Club Wednesday by the World Health Organization, UNICEF and the World Bank in the third edition of the State of the World’s Vaccines and Immunization report. As Global Health Council President and CEO Jeffrey L Sturchio said yesterday in a news release, “Child mortality has declined by more than 50 percent since 1970, thanks in large part to the tremendous strides made toward the goal of universal vaccination coverage.”

However, 24 million infants in 2007 (or about 20 percent of total infants born that year) did not receive the recommended complement of vaccines in their first year of life. Why, you ask? The panel of experts convened at the Press Club answered that the reason is not primarily because of supply. And although the average cost of fully immunizing a child is expected to rise from $6 per child in 2000 to $18 per child in 2010, Rakesh Nangia of the World Bank said that developing countries now manufacture 86 percent of the global demand for traditional vaccines. Saad Houry of UNICEF added that the overall cost of all recommended vaccinations has ticked up in large part because of the development of new vaccines while prices of many vaccines have actually fallen.

The primary reason 24 million infants are not being fully immunized, according to the panel, is inadequate delivery systems and communication. As Sturchio put it, “Governments, the private sector and civil society must continue to collaborate to reach children in the most remote and poorest places on the globe to make sure they benefit from vital vaccines and immunization.”

The challenge most discussed by the room full of vaccination experts Wednesday to reaching those 24 million infants was that of focus and equity. It comes as no surprise that remote and poorer regions in countries often have lower vaccination rates than wealthier regions with easier access to vaccines. Nangia pointed out that 10 million of the 24 million infants not reached are in India, and 6 million of that 10 million infants are in 4 Indian states. Dr. Stephen Blount of the Centers for Disease Control (CDC) said that the global health community knows how to reach the children who are not receiving their vaccinations but that there simply needs to be more drive and focus.

Another challenge is funding. WHO, UNICEF and the World Bank estimate that there is at least minimum $1 billion annual funding shortfall from what is required to meet targets agreed to by the global community. Nangia said that this issue is even more vital because of the food, fuel and financial crises gripping the world. The World Bank estimates that even with some indications of economic recovery, 90 million people worldwide will be pushed back into poverty this year, according to Nangia. Properly financing early childhood vaccinations is critical to ensuring the momentum in reducing childhood deaths is not reversed.

Perhaps another challenge is communicating the huge return on investment of childhood vaccinations to people in donor nations such as the United States. A Kaiser Family Foundation survey conducted from January through March this year found that 61 percent of adults in the U.S. said “increasing the number of children who get immunized for diseases like polio” should be a top priority for U.S. spending on health in developing countries. Furthermore, a survey conducted among registered voters by Hart Research Associates and Via Novo for the Bill & Melinda Gates Foundation from May 15-17 found that only 14 percent identified immunization of children as one of their top three priorities in helping people in developing countries. 

Despite these challenges, the chord struck by the panel Wednesday was one of optimism and enthusiasm for reaching the goal of universal childhood vaccination. The mandate of WHO and UNICEF’s Global Immunization Vision and Strategy for 2006 to 2015 is clear: if all countries provide vaccines for 90 percent of children against 14 diseases – diphtheria, pertussis, tetanus, measles, polio, tuberculosis, hepatitis B, Hib, rubella, meningococcal disease, pneumococcal disease, rotavirus, and (where needed) Japanese encephalitis and yellow fever – two million children’s lives will be saved year after year.

WASHINGTON - Representatives from non-governmental organizations, corporations, various U.S. government agencies and Capitol Hill packed into the Grand Ballroom at the Willard Hotel in Washington, D.C., for the first public dialogue with the leadership of the Quadrennial Diplomacy and Development Review (QDDR).  The panel discussion was moderated by Judy Woodruff, senior correspondent for the News Hour with Jim Lehrer, and gave insight into the reasoning for the review and the process for civil society engagement.  Although those in the ballroom and watching online engaged in a productive dialogue with Deputy Secretaryof State Jack Lew, State Department Director of Policy and Planning Anne Marie Slaughter, and Acting USAID Administrator Alonzo Fulgham, many questions still linger.  As one audience member noted, we are still waiting to find out who the next USAID administrator will be, presumably a key player in the implementation of the U.S. diplomacy and development that was being discussed.

For now, perhaps it’s best to focus on what we have heard from U.S. development and diplomacy leaders.  In his keynote address, Lew said that the purpose of the QDDR is to elevate diplomacy and development in such a way that they work better together, organize the U.S. government (specifically the State Department and USAID) so that they can better engage and work with non-state actors and move away from the mentality of emergency funding and make U.S. development assistance efforts sustainable.  According to both Lew and Slaughter, the line between development and diplomacy is already beginning to blur with the advent of interagency teams within the QDDR. 

Integration of development and diplomacy might be for the better in the eyes of the State Department, but there appears to be serious concern among the development community that integration may mean that the State Department would absorb USAID.  In response to a specific question on the issue, Ann Marie Slaughter stated that the QDDR was not about the State Department absorbing USAID, but rather about building a stronger, much better resourced USAID, better integrated within the bodies of decision making.  Some might still be skeptical, but one thing is certain and was emphasized by Fulgham.  It is imperative that USAID’s capacity as a development agency is increased so that it is able to bring countries along the development continuum, provide a space for their economic growth and ultimately their sustainability. 

It is clear that USAID is in desperate need of resources to support the kind of capacity that is being discussed, but it’s still unclear where those resources will come from.  As one audience member asked, “Is the Pentagon (Department of Defense) ready to share resources with the State Department and USAID?”  Fulgham discussed the possibility of public private partnerships to help support USAID’s efforts and all around better justification of the international affairs budget, also known as the  ”150 account.” 

According to Slaughter, the results of the QDDR are scheduled to be released by January for the 2012 budget process and will ultimately be legislated.  It’s still unclear how the QDDR, the House and Senate efforts to reform assistance and the Administration’s Presidential Study Directive to conduct a whole-of-government review of U.S. global development policy will be coordinated, but the leadership on the panel assured the audience they were all in communication.

Immediately following the panel discussion, the audience broke into various working groups to offer their input into the future of U.S. development assistance.  The leadership made it very clear that they want to hear from civil society, specifically through the working groups and sub-working groups as the QDDR unfolds.