For the 15 years that James Grant headed Unicef children became the focus of the UN. The success of his Child Survival Revolution in mobilising health services in virtually every nation provides important lessons today as we look to the future.
Soon after he took over the leadership of Unicef in 1980, Grant realised that the call of Alma Ata of “health for all by 2000” posed an impossibly large agenda in too short a time. Jim sought a limited set of interventions with quantified predictable outcome that could reach all children – “universal” was the key concept – never before had the world done something for everyone.
What was important for him was the idea of reaching every child – once accomplished, it would break the self-defeating belief that “it simply couldn’t be done”. It was his “Trojan Horse” – the proof of principle that Toynbee’s trenchant observation : “our age is the first generation since the dawn of history in which mankind dared to believe it practical to make the benefits of civilization available to the whole human race." could actually be realised. This vision became Jim’s mantra. It is hard to underplay the importance, and uniqueness, of this vision – that made Jim’s dream a possible one.
At a strategy retreat in 1982 we identified malnutrition, diarrhea and immunisable diseases as killers for which affordable and effective interventions that could prevent the death of millions of children were available but not widely used. GOBI (Growth promotion, Oral rehydration, Breast feeding and Immunisation) was born and with it the idea of the Child Survival Revolution (CSR) by analogy with the Green Revolution.
I soon learned that Grant, like most of us, learned best from first hand experience. And so we travelled to remote parts of the poorest countries to see these miracles in action. From Haiti, to Bangladesh, from Nigeria to Bolivia Jim saw the potential of knowledge placed in the hands of poor villagers and he dreamed of making it universal. He would attend immunisation outreach far beyond the reach of postal services. He saw illiterate mothers accurately mix home ORT and explain to him the value of hydration in a sick child. He marvelled at entire Indonesian villages that weighed all the babies each month and, without even the presence of a formal health worker, initiated effective local means of restoring growth in kids whose weight was faltering.
He readily appreciated the impossibility of safely bottle feeding an infant in most poor settings and the tremendous value of mother milk, virtually for free.
Grant envisioned GOBI expanding to other interventions once success was achieved in these few key high impact programs, eventually reaching comprehensive primary health care through incrementally expanding the range of high coverage interventions. By the late 1980s, the push for universal immunisation became the major thrust of the CSR, Jim needing something to reach everyone, and needing to prove it. As Jim had promised, success in immunisation became the justification for a wider agenda for children embodied in the World Summit for Children (WSC) in Sept 1990.
The WSC was the first ever gathering of world leaders for a common cause, attracting over 70 heads of state to speak for children. No event had ever come close to this level of participation, never before so many political boundaries crossed. WSC produced a precisely defined list of goals; almost all of them objective, clear, measurable, affordable, and “doable”. All other summits since have produced documents running in the hundred’s of pages. This one was encapsulated in 26 one-line goals and a few pages of introduction. The targets were time bound, to reach by 2000, designed to fall within the political lifetime of the heads of state who were signing the declaration. Jim challenged Unicef to monitor and report to the general Assembly on progress.
For most regions, the “state of children” became a standing agenda item on their Summit, and for many, a source of pride.
Para la mayor parte de las regiones, el “estado de los niños” (condición de los niños), se volvió un asunto permanente en la agenda de su cumbre, y para muchos una fuente de orgullo.
Grant often attended these Summits, in Latin America, Africa, SAARC, ASEAN, complimenting success and urging greater efforts. This was enhanced by Unicef’s annual State of the World’s Children Report and later, by the nation-by-nation ranking in the annual Progress of Nations. Jim was not averse to embarrassing states, though he preferred to highlight positive examples and cajole others to come up to that level of success.
“Keeping the promises to children” was a theme kept alive and nurtured through persistent leadership. Grant turned children into a politically viable issue, a universal concern of every household that could capture votes and win elections. He refused to deviate from the focus on a few priorities, realising that was the only way to achieve universality. He withstood the criticism about being tunnel visioned, and spoke of “staying the course” in the face of competing priorities.
No one has ever held one-to-one discussions with anything like as many of the world's Presidents and Prime Ministers as Jim Grant did in those years. He would remind every President and Prime Minister he met what the country's immunization rate was, and how many of the country's children were being killed and disabled by diarrheal dehydration or vaccine-preventable disease. Pulling out his packet of ORS he knew just how little it would cost to prevent these unnecessary deaths – citing the miniscule percent of the local defense budget to save those young lives. “For heads of state”, he said, “you have to propose a simple, doable proposition.” “Sure, you appeal to their idealism, but you also tell them how they can drastically reduce child deaths at a cost they can afford and on a time scale that can bring them tangible political dividends.” Jim said, “You just don’t say “no” to kids!”
The results within a just few years were impressive: deaths due to measles reduced by 85%; the reported cases of polio reduced by 83%, with this crippling disease eliminated in at least 110 countries – today present in sporadic cases in only 2 countries of the entire world. But, as he had predicted, it went beyond just immunisation: a million child deaths averted every year by popularising oral rehydration therapy ORT for the largest killer of children, diarrhea; millions prevented from becoming blind by lack of vitamin A; and tens of millions preventing irreversible mental retardation by iodine deficiency; guinea worm disease affecting over a million people in Africa reduced by 95% to a handful of cases today – eradication of this age old scurge now inevitable. By the time Jim died in 1995, it was estimated that 25 million children were alive that would not have been, but for the courageous efforts he spearheaded.
What would Jim Grant be promoting today, were he to be continuing as Unicef ‘s leader?
First, he would focus on the unfinished agenda – those most left behind in the progress of the last decades. In essence, Jim would attack disparity at all levels placing emphasis on reaching those left out for whatever reason. He would insist on disaggregation of data – averages always obscure the real truth –seek out those left behind. Measure, compare, and expose – restore Progress Of Nations and create other communications where success can be heralded and failure exposed.
Second, in spite of the epidemiologic transition that attracts so much attention today with resources and attention diverted to diseases of aging, mental health and over consumption, Jim would reject the contention that health services must bend to these needs unless and until we complete the job at hand. We are seeing an epidemiologic polarisation where the poor are stuck in the same trap as ever – infectious diseases, malnutrition and insalubrious environments - while attention shifts to those better off or who luckily survived the vicissitudes of poverty. The most effective interventions and the best buy still lie with addressing the most basic needs of children.
“Stay the course, till the job is finished” Jim would say, and children’s needs come first.
Third, he would transform Unicef back into the agency it was when he joined – known for field presence and field action – its staff the best informed about the intricacies of life amongst the poor in the varied circumstances of each country. Unicef staff are increasingly office bound and bureaucratically tied up.
Fourth, he would defend the right to child survival with the same intensity we defend civil and political rights. He would demand that we organise programs for survival of children with the same thoroughness and resources as we now do for elections. He would defend the right of freedom to learn to read with the same ardour we defend freedom to write in the press. He would protect children from forced prostitution and exploitative labor with the same energy we protect accused adults in a court of law. In essence, the basic rights of children must no longer take a back seat to the rights of their more articulate and politically active parents.
Fifth, he would urge us to use epidemiology, health technology, social mobilisation, harnessing modern communications technology and political activism to promote a package of relevant, locally identified activities that would intensify and extend the CSR within the control of and responsibility of each community and political jurisdiction. Real advances in survival and health are largely in behaviours and given the power of modern communication tools, behavioural change is possible on a much more ambitious scale than ever before.
Sixth, he would strengthen Unicef support for education, especially of girls insisting on universality, practicality and quality. Somehow he would see that this most critical element of societal transformation spearheaded all development agendas across nations and agencies.
Seventh, he would forge an alliance amongst all partners – integrated concerted effort. More than ever, agencies need to come together backing a common effort and approach – not competing.
Global Fund and PEPFAR have mobilised billions for HIV while programs for children languish. Grant convinced scores of leaders that speaking out for children, allocating state resources and mobilising society are sound political strategies – where do we see that today? Why have they forgotten such a basic lesson? Jim would put children back on the political agenda.
Eighth, Jim would be planning ahead for 2030 – highlighting the success of the MDGs and preparing for the next set of challenges, stretching the limits of the possible, harnessing the latest technology and always harping on the mantra “children first”. He would place children as the sensitive indicator in each of the seventeen 2030 SDGs recently adopted by the UN.
Finally, and most tentatively, I suspect Jim would take up the leadership to end the stranglehold that the military and its industrial partners have over every aspect of our lives. In the last half of the past century, more children lost their lives in wars than did soldiers. The economic devastation to social programs by the military has been even greater. While he was always reluctant to stray into areas not within his mandate for children, I think he would, by now, agree that there can be no secure future for the world’s children as long as the vast resources of the richest peoples are dedicated to the aggressive pursuit of power, profit and war.
With his energy and drive, he just might convince us that the war machine must be curtailed, dismantled to make possible the dream that drove Jim Grant. He saw through children, the chance of peace and decency for everyone. Indeed, children are a valid aim in themselves, but more so a means to uncover the humanity in us all and bring about a better world in the process. This is the legacy he left for us – the challenge lives on.
Jim Grant achieved what he did by exerting leverage. 'Give me a fulcrum” said Archimedes, “and I will move the world'. Jim's fulcrum was UNICEF. He could not have done what he did standing in any other place. Not as an American politician, not as the head of a large non-governmental organization, not even as the head of any other UN agency. UNICEF is a household name in virtually every country of the world. It is a name that commands respect and affection everywhere. It is the name that opened the doors to Jim Grant. And it is the name that predisposed those inside those doors to listen. That fulcrum is there yet today, waiting to be used to move the world.
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