The challenge facing young women in the Middle East and North Africa are in fact enormous. Not only are their numbers unprecedented with the onset of the youth bulge phenomenon, they are increasingly educated, as the gender gaps in education disappear, and in fact reverse in many cases. They are also marrying later, leaving them plenty of time between finishing school and getting married to enter the workforce and start a career.
The challenge is compounded by the fact that in many countries of the region significant economic restructuring has occured away from a state-led economy toward a more market oriented system. While this may have led to faster economic growth and more efficient production structure it has negatively affected the status of women in the labor market.
It is well established that the public sector is fairly egualitarian in its hiring, with little differentiation between men and women, so long as they have the requisite educational certificates. Private sector firms, on the other hand, in most of the countries of the region, are reluctant to hire women, except in a fairly narrow set of occupations and activities. This entry discrimination against women in the labor market results in a significant wage gap in the private sector in favor of men, even when qualifications and experience are taken into account. The withdrawal of the public sector as a major employer has thus resulted in a narrowing of opportunities for educated women in wage and salary employment, leading many educated young women to simply withdraw from the labor market. We thus notice that in a number of countries, participation rates for educated young women are falling in line with the drop in their chances of obtaining public sector employment.

Resolving these challenges is not going to be easy. Opening up the private sector labor market to greater female participation requires some legal changes like changing laws and regulations that impose significant costs on employers who hire women, including paid maternity leaves, long unpaid leaves for child rearing, etc. Although, these are necessary benefits, they should not be imposed on employers, but, instead covered through the social insurance system. These aren't the only obstacles to female employment in the private sector, but addressing them would be a start. Evidence indicates that countries that engage in the export of manufactured goods, such as ready-made garments, processed foods, and electronic assembly do better in terms of female participation in private sector activity. Morocco, Tunisia are good examples of that in the region.

To sum up, one of the biggest challenges facing the MENA region now is that most countries have succeeded in closing the gender gap in education, but most still have serious obstacles in the labor market that prevent these women from making use of their abilities in the economy.

Rising oil prices could either be a blessing to the countries of the region or a curse depending on the way the new-found wealth is managed. If high oil prices will lift the pressure toward necessary reforms by filling the coffers of the government and reducing the urgency for change, they could have a fairly negative effect. If on the other hand, the new-found wealth is used to help compensate losers and make the introduction of reforms easier, then they could be a blessing.

What are the necessary reforms? First, there has to be a virtual overhaul of the education system away from a system producing credentials to qualify people for public sector employment to one that imparts young people with real skills to be productive in an increasingly globalized economy. This means moving away from rote memorization to more cognitive skills, more problem solving, more research and communications skills. The education system also needs to be more responsive to the needs of an increasingly privatized economy. This means giving young peopple and their parents more choice over what schools they go to, what fields to enroll in and making schools more accountable to the community.

Second, the move away from guaranteeing employment in the public sector for educated youth must be consolidated. Although this has led to the formation of a large middle class in many countries, it has greatly distorted the labor market and the education system by emphasizing credentialism rather than skills. It has also raised expectations and encouraged queuing for public sector jobs, leading MENA to have the highest unemployment rates in the world.

Third, we need to develop a wide range of opportunities for skills development outside the formal education system. These new opportunities need to be market-oriented to respond to real needs and have significant involvement of the private sector in their provision. However, they need not be totally privately financed. Public financing can be used in judicious ways to support these market based opportunities.

Returning to political instability, we need to realize that while it is true that some political instability is imposed from the outside as a result of geo-political conflict and competition over resources, conflict and instability are also often the result of demographic pressures that are not adequately addressed. The presence of large numbers of underemployed and frustrated young men, with potential access to weapons, is often a recipe for civil conflict. Thus the youth bulge could provide significant demographic dividends, but if not dealt with with the right policies, could result in political instability and civil conflict.

The youth bulge is a natural stage in the demographic transition that nearly all societies have gone through. The demographic transition is the process by which societies go from a situation of high fertility-high mortality to a situation of low-fertility, low-mortality. The first stage of the transition involves falling mortality, while fertility remains high. That stage is characterized by very high population growth as more children survive early adulthood and fertility rates remain high. Eventually, fertility begins to decline and the number of children starts to stabilize. That stage of the transition, after the onset of fertility decline, is the period characterized by a youth bulge. The large cohort of young people born during the previous phase form an increasing share of the population, a phenomenon we call the youth bulge.

For now, and for the foreseeable future, the youth bulge is leading to the largest cohort ever to enter the labor market. Once they make it into the labor market, they will contribute to a period of falling dependency ratios. During this period the number of working age individuals relative to the size of the population increases, leading to what is referred to as the demographic dividend. It will take about 40 years for the youth bulge to actually turn into a demographic burden and a smaller workforce as the members of the youth bulge cohort start to retire. This would be similar to the retirement of the baby boom generation that was born in the two decades following the Second World War in the US and Europe. It took about forty years for that generation to reach retirement age. Countries in the MENA region will have to worry about that sort of "greying" of their populations, further on in the future. Now the challenge is to absorb the growing labor force into productive employment to realize the demographic dividiend.

Jane, I've addressed this question to some extent in a previous answer. There is no question that the challenge of the youth bulge is compounded by a heavy legacy from the past. The peak of the youth bulge in the MENA region, which is about now, is coming at a time of major shifts in the economy, which increasingly requires skills relevant to a competitive globalizing world economy. The education and training system of the region, however, have yet to experience much restructuring, along those lines. They are still oriented toward the production of credentials rather than skills. Job markets had been dominated by the public sector, which reward these educational credentials. Now, the growing private sector in most countries is not willng to pay more for formal educational credentials unless they translate into productive skills, leaving a lot of young people with worthless human capital investments.

The private sector is also unwilling to give young new entrants the sorts of job security and social protections that the public sector used to provide, thus the proliferation of informal employment. Young people will have to reduce their expectations about getting secure lifetime employment and accept a reality where they will need to progress in the labor market through many jobs over their careers, where they gradually accumulate experience and skills

I'm not really an expert on cultural matters, but I can see things moving in two directions. In some countries, such as Iran and Saudi Arabia, where the state is imposing a certain cultural orthodoxy, I can see that the reaction of some young people would be to reject these cultural values. In other countries, young people may be tempted to express their frustration at their poor life prospects by emphasizing religion and traditional values.

In either case, my feeling is that states need to provide space for debate and dissent outisde the religious realm. They should also promote tolerance of different ways of behaving and thinking. Enforcing cultural orthodoxy will not work, just as denying people the right to express their religious identity often backfires as well.

You are quite right that in many, but not all, Middle Eastern societies a reverse gender gap is developing in education. when it occurs, the reverse gender gap is largest at higher levels of education, especially the univesity level. The primary reason for this is that while education systems have become equally accessible to young men and women, labor markets have not. Women still have much poorer prospects in the labor market, especially in the private sector. Although this can potentially affect the decision to get an education in two opposing ways, in fact, it ends up leading to more rather than less education for young women.

On the one hand, poor prospects in the labor market may lead parents to conclude that it is not worth investing in the education of a daughter since the returns to that investment in the form of future wage income will not materialize. However, much of the return to education for women in MENA does not occur in the labor market, but in the marriage market. As male education rises, educated women are highly prized as wives and mothers who can contribute to building the human capital of their children. Thus education still has substantial benefits.

On the cost side, one of the main costs of an education is income foregone while in school. Individuals give up the ability to make money though work while in school in order to have a higher income in the future. Since women's job prospects are poor, their opportunity cost to remain in school is also low compared to that of men, leading them to stay longer in school. This is especially the case when the age at marriage is rising and women's heavy domestic responsibilities are somewhat delayed.

Eventually, the increasing numbers of educated women will no longer be satisfied with their domestic roles and will begin demanding a larger economic and public role. Such demands are bound to further advance social development in the region.

Besides the large gap in incomes between the populous countries of the Middle East and North Africa and Europe, the contrasting demographic profiles of the two regions provide a very strong impetus for migration. There is a surplus of young people in Egypt, Syria, Morocco, and Yemen and there is strong demand for young workers in Europe to care for an increasingly greying population. In that sense, MENA is no different from countries in Africa and South Asia, but the proximity of many MENA countries to Europe may make the lure stronger.

One should keep in mind however, that there is another set of destination countries in the oil-rich countries of the Gulf. These countries are now relying essentially on South Asia for many of their labor needs, but are increasingly importing young professional from other Arab countries to make use of their language skills. Unskilled workers from MENA generally have few prospects in these oil rich countries at the moment.

What are the policy implications of these migratory flows? First, destination countries need to realize the very powerful economic and demographic forces that are leading to this migration and institute policies that encourage organized and legal temporary migration. Simply closing their doors, will lead to growing flows of illegal migrants, with all the potential for exploitation and endangerment that such flows can create. Sending countries need to negotiate labor exchange agreements to faciliate these legal migration flows. These steps are not easy because of all the cultural and social issues that migration raises, but are necessary if the problem of illegal migration is to be addressed.

There is no question in my mind that fertility decline in MENA was brought about by the improving education status of women and the fall in infant and child mortality rates. Women's education leads to fertility decline in two main ways. The first is delayed marriage, which is a phenomenon that has occurred in all countries where fertility decline has occurred and accounts for a significant fraction of this decline. The second is low desired family size within marriage, and that is related to the desire of more educated women for quality of children vs quantity and is also related to the opportunity cost of women's time outside the home. It is also significantly related to the confidence that one's children will survive, which results from declining infant and child mortality.

Now, for the decline to be realized under these conditions, women have to have the opportunity to control their fertility and this means that states must be supportinve of family planning and make family planning methods readily available. There are a number of cases where this has not happened despite rising education levels among women, like present day Saudi Arabia and Iran in the first ten years after the revolution.

This brings us to Iran, which is a bit of a special case because of the role of the Islamic revolution there. If one traces the path of fetility decline in Iran prior to the revolution, we can see that Iran was on a declining fertility path since the early seventies, caused by the factors mentioned above. The revolution comes in 1979 and makes it extremely difficult for women to control their fertility despite the presence of all the social pre-conditions of fertility decline. This actually results in a temporary reversal of fertility decline and a unique situation of increasing fertility following the onset of fertility decline. Once the Islamic Republic decided to reverse it policies in 1990 and began promoting family planning again, what happened in Iran was an episode of catch up decline in fertility with one of the most rapid episodes of fertility decline in the world. In fact, Iran is now where it would have been had the decline that began prior to the revolution continued at the pre-revolutionary pace without the interruption of the first ten years of the Islamic republic. The moral of this story is that there are very powerful social forces behind the fertility transition that even a powerful socially-conservative revolution could not reverse in a permanent way, but that could only resume once women were allowed the means to reach their desired family size.

The story of the Maghreb is somewhat different. The underpinnings of the decline are still the two factors mentioned above, but the pace of the decline was helped by the higher economic participation of women in the Maghreb, which raises women's opportunity cost of time outside the home and thus the cost of having children.

The prevalence of genital mutilation (FGM) varies significantly across the region. Genital mutilation practically does not exist in the Asian countries of the region, except in the coastal areas of Yemen that are affected by population flows from the horn of Africa. FGM is very common in Egypt and the Sudan and less common in North Africa. So it is essentially an African phenomenon that has spread to parts of the MENA region through the Nile Valley and the Western edges of the Sahara.

There are now significant efforts to eradicate FGM in some countries, most notably Egypt. It is now a public issue and a great deal of public debate is taking place about it. The government has taken a strong stance against it and a law criminalizing it is now before parliament. There is also some evidence that prevalence rates have declined among young women, but the impact of the recent efforts will not really be felt right away.

The economic policy arena in MENA has shifted dramatically in favor of private enterprise in recent years, especially in the formerly socialist countries, such as Egypt, Syria, Algeria, Tunisia, and Yemen. However, much remains to be done to promote the growth of small and microenterprises and lift the regulatory burdens that force them to stay informal and therefore small. Many of the policy changes have favorably affected the environment faced by larger entities and they have been growing rapidly. The reforms needed to improve the business environment for smaller firms are much more painstaking and require a significant improvement in the governance structure, such as reduced petty corruption at varous levels and a more transparent regulatory framework.

Finally, I would like to caution that only a very small proportion of young new entrants will become successful entrepreneurs. The vast majority need to have good opportunities in wage and salary employment in order to be productive members of their societies. Entrepreneurship requires significant skills, experience and market knowledge that most new entrants simply lack.

I actually see this as a very positive phenomenon so long as these universities maintain the same standards of education in these institutions as the ones of the parent institutions. The region needs educational institutions that promote critical thinking, analytical skills, problem solving and competition from these new institutions will induce local institutions to provide these skills. The main caution is that these should not be thought of as money making ventures that provide a cachet but a very different quality of education from that of the parent institution.

Absolutely. The population change poses a challenge to policy and may exacerbate the effect of wrong or misguided policies. If the right policies are adopted, it could actually become a significant asset as it was in East Asia. What essentially needs to be done is to improve the quality of human capital through higher quality of education and insituting policies that make better use of that human capital. East Asia did that by investing heavily in education and by adopting outward oriented, export-led development policies that made good use of the educated youth that were coming on line.

Governments could clearly see this coming, but as you know, they usually have a rather short planning horizon and try to deal with the most urgent problems first. The problem with this is that it is a pretty long-term phenomenon that needs significant advance planning. Most governments in the region are in crisis management mode. This is not specific to the region. Witness the US government's peformance in addressing the crisis of the social security system brought about by population ageing.

Hi,

We would love for you to join us. In the White Ribbon Alliance for Safe Motherhood we believe everyone can "Play your Part".

If you go to our web site - www.whiteribbonalliance.org your association can get involved with the H.Res., which "recognizes maternal health as a human right" and calls upon the US government to "make a stronger commitment to reduce maternal mortality at home and abroad through greater financial investment and participation in global initiatives."

We look forward to you joining us! Theresa

In 2007 through the Health Policy Initiative I worked with Emily Sonneveldt and the Reproductive Health Response in Conflict (RHRC)Consortium on a study titled "Understanding Operational Barriers To Family Planning Services in Conflict-Affected Countries: Experience From Sierra Leone." The findings from this study can be accessed through the RHRC Consortium who have a wealth of information about these issues.

The other group that is a resource is the Inter-agency Working Group on Reproductive Health in Refugee Situations (IAWG).

These are wonderful consortiums and working groups who have country examples of best practices and what has worked to address these issues.

Continuing to work in partnership and sharing what we know as best practices and holding governments accountable I believe can help curb this this terrible trend. Thank you for your question. Theresa

This has been an ongoing debate for many years with limited aspects being studied throughly. One thing to always keep in mind when obstetrical complications arise, TBA's can not handle the emergency and are often not a part of any referral system.

There are some promising approaches at the community level. One being the home based life saving skills approach championed by the American College of Nurse Midwives - www.midwife.org/news.efm.

For detail study on TBA and pregnancy outcomes please reference the article by Lynn Sibley and Theresa Ann Sipe -Titled "What can a meta anaylsis tell us about traditional birth attendant training and pregnancy outcomes?"

Thank you for your question. - Theresa

This is an issue of increasing concern for all the professional associations, such as FIGO, ICM, ACOG, ACNM, etc. There are studies that are coming out indicating an increase in cesarean sections and overmedicalization of births. Monitoring of the percentage of births that end in a cesarean section is occurring in a number of countries with close anaylsis to wealth quintiles to determine whether these are the result of emergencies or planned by the wealthier quintiles.

Please refer to the websites of the professional associations for more information on this topic.

Thank you. -- Theresa

There are a number of different cash transfer programs underway including voucher systems, provider pay for performance, referral transfers, and cash for facility deliveries. At this early stage, there is not enough evidence on reduced maternal mortality, though increases in facility deliveries have been documented. The verdict is still out but this is something to watch as a promising approach.

Thank you == Theresa

There is significant evidence that health systems need to be in place to really reduce maternal mortality. However, there are some promisig interventions to address specific causes of maternal death in resource constrained countries. For example, community based family planning programs as essential, life-saving, and feasible in countries with poor health systems. Also, interventions for treatment of postpartum hemorrhage at the community level. You can reference the excellent work that PATH is doing through the Prevention of Postpartum Hemorrhage Initative (www.path.org/projects/preventing-postpartum) and studies by JPHIEGO. Also as referenced in an early question, home based life saving skills through the American College of Nurse-Midwives (www.midwife.org/news.efm)

Thank you - Theresa

This is very much at the heart of the WRA's advocacy agenda -- that maternal mortality must be on the agenda of all economic development partners. Please visit our website: www.promisetomothers.org to learn more about the framing of these messages. For example, we know that the economic losses to the world by not addressing maternal mortality are far greater than the economic investment required to reduce these needless deaths. On the Promise to Mothers Lost campaign, we will be pressing for these commitments and investments by global and national leaders.
Please join us.

Thank you - Theresa

NGOs have a critical role to play in reducing maternal mortality. In particular, NGOs at the community level play a major part in addressing the first two delays - through their work in addressing birth preparedness and complication readiness and different transport schemes.

One of the other challenges, not just for NGOs, but larger international bodies is actually measuring MMR effectively. There are some promising tools that have been developed by Immpact -- please visit: www.maternal-mortality-measurement.org

Also, NGOs are tremendously important in advocating for adequate resources, supportive policies and programs, and holding governments accountable to promises made.

Thank you - Theresa

Global estimates for maternal mortality ratios:
1983: 500,000 (Royston and Armstrong, WHOP)
1990: 509,000 (Hill and Stanton, WHO, UNICEF 1996)
1990, revised: 585,000 (above reference)
1995: 515,000 (Abouzahr and Waardlow, WHO/UNIEF/UNFPA, 2001)
2000: 529,000 (WHO/UNICEF/UNPFA, 2003)

Main causes globally:
--severe bleeding (24%)
--eclampsia (12%)
--unsafe abortion (13%)
--infection (15%)
--obstructed labor (8%)
--other direct causes (8%)
--indirect causes (20%)

Thank you - Theresa

I agree fully that it takes efforts at multiple levels and by diverse stakeholders. We are committed to this approach as an alliance and encourage you to join the White Ribbon Alliance in India. Contact details can be found at www.whiteribbonalliance.org

Thank you - Theresa

It is agreed we know what to do and how to do it, what is lacking is the political will and commitment. That is why we are engaged in both a global and national level advocacy campaign to hold leaders to these global commitments and endorsements to ensure that the resources, systems, and workers are a priority. This is potentially an incredible time for global commitments and resources to really be put behind these proven practices.

Jeremy Shiffman has done an excellent analysis of why maternal health has not received the needed political commitment, why this commitment is the missing link, and what some key factors are. His work can be found through the Center for Global Development.

Thank you - Theresa

On your first question, please reference my early answers related to community based approaches.

On your second question, one key commitment for African governments is to commit to the Abuja Declaration of 15% of government budgets to be allocated to health. This is critical step in strenghening the health systems and providing quality maternal health services. Another important strategy: the African Road Maps for accelerating the reduction of MMR == which include crucial integration of family planning, malaria, HIV/AIDS, child health with maternal and newborn services.

Thank you. - Theresa

This issue is a crticial one across Africa. The White Ribbon Alliance in Tanzania has taken this on as its primary advocacy issue - including increasing the number of qualified workers, improved training, incentives, supportive work environment, etc. More information on their work can be found on the WRA website www.whiteribbonalliance.org

In addition, we have developed a guide based on lessons learned in building, maintaining and sustaining alliances. This is also available in the resource section on the WRA website.

Thank you - Theresa

1- One of the contributing factors may be the fact that many donor agencies have seperate pools of funding and seperate strategies for family planning versus maternal and child health. Consequently, it has been challenging to integrate the two, despite the evidence that FP is integral part of MNH programs.

2-I agree there has not been enough emphasis on male involvement, but there are many organizations that are working on this and having success. One example is Save the Children's work on approaches to involving men and religious leaders in family planning and maternal and newborn health. For further information, you can visit the Save the Children website.

Thank you - Theresa

By working in an alliance, we found there are very positive measures being taken to support women during pregnancy and childbirth. By working with diverse stakeholders, such as civil society, international organizations, faith based organizations, professional associations, and local organizations and government, we can create empowering and supportive environments and utilize innovative strategies such as "social watch" approaches to monitor the quality of care, including the treatment of women and family involvement, at the facility level. There are also innovate approaches at the community level. It is our hope that by having involvement and collective action from the household to the district to the national level will improve the overall social attitudes towards women.

We are working on exactly this issue -- how to engage major economic development instutions in addresing maternal mortality - it is an issue of economic development. We had a very successful engagement with the IMF and World Bank during the spring meetings of the IMF/World Bank Development Committee in Washington DC. One of the factors that has contributed to these institutions not being on the forefront of this issue has been parallel programming - and this is something that the World Bank in particular is striving to address through a health systems approach that puts maternal and child health at the heart of the health system. We applaude this progress - and will continue to engage these institutions and their leadership and we encourage you to also do that at the country level. Also note that Ministers of Finance from developing countries have an active voice and important role both in influencing these global institutions as well as making decisions and commitments at the national level (such as Abuja Declaration). Please join with us.

Thank you - Theresa

Hi, All, Matt Lynch here from Hopkins-Center for Communication Programs (http://www.jhuccp.org/).I'm the Director of the Global Program on Malaria. Unfortunately, Dr. Tshefu is unable to join us today, so I am filling in.

In regards to your question, its a good one. There are some interesting projects using cellphone technology in other African countries to address this issue. A project in Tanzania run by the Mennonite Economic Development Associates (www.meda.org/) that is monitoring distribution of insectiside treated nets from antenatal clinics.

Also, in Mali, NGOs in the field are assisting the National Malaria Control program by reporting stock outs of drugs and other distribution problems to the NMCP.

So there are some interesting developments out there in this field.

Of course, both malaria and HIV/AIDS are serious diseases that require investment.

The amount of distribution is determined by the willingness of donors to invest, and at this time there is less support for malaria than HIV/AIDS. However, that is changing as more and more donor organizations recognize the importance of malaria and commit to join the fight.

There are also strategies being developed to create a global subsidy which is intended to help bring the price of drugs down.

While DDT is one of the 12 WHO approved insectisides for malaria control, due to the high cost and operational complexity, DRC does not use any kind of indoor residual spraying at this time.

With the right funding partners and methods, net ownership has been on the rise in the DRC.

Recently mass campaigns linked to measles vaccination efforts have been an effective tool for increasing net ownership.

While there are challenges in distribution in DRC, we have seen some success- for example, a Global Fund and World Bank program from 2006 successfully distributed over 3 million nets.

A larger challenge, however is ensuring availabilty on a regualar basis- due to supply chain issues. Here, partnerships with the private sector are an attractive option to solve this problem.

Yes, strong malaria programs depend on integration with antenatal services and quality treatment services.

RBM's plan is an ambitious plan that is important and well worth doing. For the next few years, the focus must be on rapidly expanding proven control measures, such as long lasting insecticide treated nets, intermittent preventative treatment for pregnant women, prompt and effective treatments, and indoor residual spraying.

The plan also importantly includes the need for educational efforts - the technical assistance that managers and health workers need to use the tools for fighting malaria effectively. In terms of funding, this support must come from donors. In the past USAID has been a leading and successful provider of these needed educational efforts.

Litter which contains standing water is a serious public health issue- the mosquitoes that breed in these types of areas can carry dengue and encephilitis. However, the mosquitoes that carry malaria do not breed in these types of areas.

Your question raises the importance of accurate and actionable information on public health threats. With the right infromation, people can protect themselves effectively from many of these public health problems. That is why it is so important to continue to dedicate resources to educational efforts in addition to funding needed medicines, nets, and other commodities.

Dr Tshefu discussed this eloquently in her presentation yesterday, which you can watch here online:
http://www.kaisernetwork.org/healthcast/ghc/23apr08


There are many challenges facing the DRC, including poverty, lack of infrastructure, and political instability.


The biggest problem is lack of resources to implement campaigns that use proven methods to fight malaria. The DRC has very little govenrment investment in health, and the recieves very little donor money compared to other sub-saharan African nations.

Dr. Tshefu told us she was confident that with investment, there could be significant progress in fighting malaria in DRC. She also specifically noted the need for more schools of public health in the DRC.

Anopholes is a genus of mosquito with various species. Some species are more effective at spreading the disease than others.

Availabilty of ACTs in DRC is still a major problem. Most countries in subsaharan Africa have adopted the policy of using ACTS, but availabilty remains a problem.
In the DRC, the short shelf life of ACTS is a particular problem because of the weak distribution systems and supply chain issues.

There are approximately 60 million people in the DRC, and 100% of them are at risk to develop malaria. Because the transmission season is year round in the majority of the country, prevalence is high.

ITNs are generally not easily avaialble in the DRC except during large scale campaigns. Nets are supplied by a variety of sources including NGOs donors via mass campaigns and in the private sector, as they are sold in shops.

The Kinshasa School School of Public Health is the only public health school in the DRC.

Conflicts have contributed to the challenges in fighting malaria- with people displaced they are more vulnerable to developing malaria, the supply chain is disrupted. Generally, the risk increases at the same time availabilty of treatment decreases.

USAID, the World Bank are two other supporters of the malaria program in the DRC.

Currently, while the DRC is not included as a PMI country, what Dr. Tshefu requested in her presentation yesterday was greater resources in the non-PMI USAID budget devoted to DRC.

Successes have largely occurred to date in countries with relatively well developed infrastracture, such as Italy, Thailand, and South Korea.

Effective malaria control depends on identifying and implementing the correct mix of interventions for each individual setting. For example in the DRC, indoor residual spraying is most likely to be used effectively in the eastern mountainous region, whereas insecticide treated nets are more easily distributed in isolated rural communities.

DDT, and other insecticides, work best in more densely populated areas where houses are close together and many can be sprayed in one day.

The National Malaria Control Program of DRC, developed in consultation with WHO and RBM, which call for the use of artemisinin and amodiaquine at that level. The current strategy does include vector control-- insecticide treated nets are being recommended, and indoor residual spraying is being considered for the eastern highlands.

More attention is being given to the effective use of funds for malaria control.

Increasingly, the use of the coordinated National Malaria Control Program in each country has improved the process for implementing effective and coordinated efforts. In addition, the NMCPs have strengthened their capacity for financial management.

This is reflected in the number of grants issued by the Global Fund for malaria- all Global Fund grants take into account performance for continued funding, and last year we saw the highest ever number of Global Fund grants for malaria.

Malaria is most effectively addressed through a comprehensive strategy based upon guidance provided by the World Health Organization (WHO). Key components of the strategy include: for prevention, the use of insecticide-treated nets, indoor residual spraying with insecticides, the intermittent treatment of pregnant women and, for treatment, the administration of artemisinin-combination therapies. These strategies should be implemented based on the needs and appropriate application in local communities.

The U.S. President’s Malaria Initiative (PMI), the Global Fund to Fight AIDS, TB and Malaria and the World Bank Malaria Booster Program are three initiatives making great progress in reducing malaria’s global burden. Working through strong national malaria control programs in malaria-endemic countries, these initiatives are proving effective. However, long-term gains will depend upon sustained resources, strong health systems, monitoring and evaluation to ensure intervention effectiveness and the coordination of malaria control efforts with efforts to address other health and social challenges facing communities.

You have raised two important issues critical to global efforts to reduce malaria’s global burden.

First, regarding sanitation management: Poor sanitation is one of many reasons why malaria continues to thrive in many areas and has begun to emerge in locations, like cities, where it was once eliminated. In addition, intensified irrigation, dams and other water related projects in once remote areas contribute to malaria’s burden. Like you, the WHO believes that better water management can reduce malaria transmission. Agriculture and water projects may make policy or program considerations when designing new programs to have minimal impact or otherwise integrate malaria prevention and treatment aspects into work to protect the health of local communities.

Second, regarding behavior change: for too long, malaria has been considered a fact of life. Now that interventions are reaching more communities, people see that it isn’t so. Malaria prevention and treatment is heavily reliant upon the proper choices before and immediately following infection. Examples include the proper (consistent and appropriately hung) use of a bed nets, early recognition of malaria symptoms (fever, lethargy) and the appropriate dosage and full administration of treatment regimens. Health professionals, community workers and mothers are equally important parties whose behaviors are critical to malaria prevention and treatment.

As with advocacy for basic malaria resources, securing resources for sanitation efforts and behavior change rely upon communicating past successes and articulating, based on evidence, what may happen without these elements of malaria control.

Thanks to significant investments in recent years by the U.S. President’s Malaria Initiative (PMI), the Global Fund to Fight AIDS, TB and Malaria and the World Bank Malaria Booster Program, we are seeing unprecedented progress in the fight against malaria in sub-Saharan Africa.

For example, in 2007, Ghana announced that it halved the number of malaria deaths and cases dropped from 3.5 (2003) to 3.1 million (2006). The program was based upon community workers who raised awareness, helped to sustain demand for malaria interventions and strengthened home-based care of malaria.

In addition to Ghana, Zambia has experienced a drop in malaria incidence and deaths. Similarly, Tanzania has had a measurable reduction in mortality over past five years. The countries are demonstrating what is possible with sufficient and sustained resources, donor coordination and strong national malaria control programs.

Donor and government efforts in many countries are being complemented by increased activity by civil society and local communities that are demanding resources for malaria control efforts and taking control of education, prevention and treatment at the community-level.

Challenges: As you know, malaria is an environmentally driven disease. Therefore, efforts must be substantial and sustained. As we’re seeing, progress is quite possible and promising for a future in which malaria’s impact on children, communities and nations is significantly diminished.

As with most biologically driven infections, malaria is a smart disease. It adapts to changes in the environment – oftentimes more quickly than human interventions can be developed or reach those in need. The continual shift is due to changes in the parasites that grow resistant to current drugs and the mosquitoes that grow resistant to insecticides.

As we have seen with the widespread use of monotherapies, drug resistance has grown. In 2006, WHO issued guidance to replace the use of monotherapies with combination therapies. This move lengthens the efficacy lifespan of drugs.

How can drug resistance be addressed? Among other strategies: 1) stop use of monotherapies which promote drug resistance, 2) support appropriate diagnosis to reduce unnecessary use of malaria medicines, 3) invest in research and development for new classes of drugs, 4) rotate insecticides used for spraying and bed nets and 5) invest in development of new classes of insecticides. Drug resistance is best viewed as inevitable which should motivate a continuous search for new intervention tools and techniques.

In the short-term, existing interventions that are known to be effective should be made available to all in need. Current efforts must be supported financially, by national governments, strong health systems and accepted by local communities. Interventions must be monitored for effectiveness and opportunities to improve efforts.

Complementing direct program efforts must be an ongoing investment in research and development for new diagnostic tools, prevention strategies and treatment regiments.

As I am sure you are aware, there have been recent calls for malaria eradication. This call to action has been made and attempted before. There are many steps between the current situation with malaria and eradication. Therefore, the short-term focus must be on control. As progress is achieved, countries that are able in terms of financial and health systems resources and an amenable physical environment can work toward elimination. Eradication is a long-term goal that reminds us of the need for long-term investments by the international and local communities.

In 2005, over 17 million of the country’s 28 million people were at risk of malaria. While the majority of the burden is in sub-Saharan Africa, malaria is certainly a risk in non-African nations and deserves attention. USAID’s first presence in the country was 1954. First efforts at eradication were in 1958.

The Nepalese government has recognized this and has a strategy based on early detection and treatment, laboratory capacity, the use of bed nets, indoor spraying where appropriate, skilled health staff and field research. We are seeing very impressive successes where there are committed efforts by governments and communities to address malaria. Investing in public campaigns and basic community education is absolutely necessary to get the best return on investment in malaria control efforts.

Particularly for remote communities, the lag time between accurate diagnosis and treatment is too often the difference between life and death. As a result, many treatments are presumptive, based on physical presentation of fever and other symptoms rather than on diagnostic testing that may require equipment and trained technicians. While this approach saves many lives, it also results in the sometimes unnecessary use of medicines which can lead to drug resistance.

Rapid diagnostic tests (RDT) are intended to address this challenge by allowing on-site diagnostic testing to verify clinical diagnosis. The widespread use of RDTs is limited largely by cost (an estimated $25/test) versus the gold standard of blood smear (an estimated $7/test). Even this less expensive strategy is not available in all communities in need. Continuous investments in research and development in tools like microscopy and RDTs can lead to reduces cost and wider dissemination/use over time.

An estimated 88% of Somalia’s population is at risk for malaria. Currently artemisinin-combination therapies (ACTs) and rapid diagnostic tests (RDTs) are available in hospitals. Local clinics are improving their capacity to treat simple cases of malaria.

Somalia is a Global Fund recipient (Round 2, Round 6). Since baseline, nearly every malaria performance indicator has improved significantly. This includes: the number of households with a bed net, the percentage of children under age five and pregnant women sleeping under nets, malaria knowledge and the percentage of epidemics detected and controlled.

Continued public education, visible commitments by the government via campaigns (including those integrated with Immunization campaigns and maternal-child health programs) and demonstration of the successes possible (particularly saving young lives) can reinforce the importance and return on investment in malaria control efforts.

The Somalian government has developed a 10-year communications strategy (2006-2015). Health workforce, community mobilization and advocacy are critical to sustain Somalia’s progress.

Please see previous response to Dr. F.A Badru.

International donors have enabled malaria endemic countries to make significant progress in the fight against malaria. Resources have come from developed country governments, most notably through the PMI, World Bank Booster Program and the Global Fund.

Corporations and other private industry companies are increasingly engaging in the fight against malaria. Exxon Mobil, Standard Charter Bank and member organizations of the Global Business Coalition are demonstrating their commitment through a number of public private partnerships.

Malaria eradication is a long-term goal that will depend upon significant and sustained investments from a diverse set of supporters including innovations generated by the chemical industry.

Health education is a critical component of disease control efforts, particularly ones that rely on behavior choices. At the community-level, word of mouth and peer encouragement is often the most effective tool toward communities engaging in appropriate malaria prevention, diagnosis and treatment behaviors.

Examples of reaching low-literacy communities include: folk theatre in India – this is an effective mass media strategy that delivers key malaria messages and raises awareness; Population Services International (PSI) has developed pre-packaged treatments that enable mothers to deliver home-based care to children affected by malaria; other examples include billboard displays, television commercials, illustrations and other visual depictions to replace written instructions and radio skits.

Malaria is a disease of the environment. It is more easily transmitted than HIV, i.e., mosquito bite vs. exchange of a significant amount of bodily fluids. Malaria is so common in many areas that it has long been considered a fact of life. Now that impact has been demonstrated, countries and international donors are recommitting to anti-malaria effort.

Malaria’s threat is perpetuated by many factors. For example, even when bed nets are available, they may be used by the breadwinner (father) rather than children or pregnant women who are at greater risk if infected. Some regions continue to use monotherapies (if there is not a high prevalence or high resistance). ACTs are used more in regions with high prevalence and high resistance rates and should be more widely available in the future, but are more expensive. Finally, climate change, urbanization and migration, trade, and the increased mobility of people are aggravating the situation. As a result, malaria is spreading to previously non-endemic areas.

Malaria has many links to other tropical diseases. There is also increasing evidence to co-infection with HIV. This fact highlights the importance of strong health systems able to address the menu of health concerns and where education, prevention, diagnosis and treatment of malaria are integrated with other health conditions that can exacerbate or be worsened by malaria.

Malaria is a tropical disease that thrives in the sub-Saharan African environment. Please see previous comment about a comprehensive approach to prevention, care and treatment. Rapid scale up of existing interventions is critical, as is sustained control. Over time, countries can move toward elimination. This will require getting available interventions to communities in need and simultaneously investing in research and development of new tools and interventions, including a malaria vaccine.

To the contrary. Malaria is currently one of the top global funding priorities. This is demonstrated by bilateral efforts by donor nations including the U.S., multilateral initiatives like the Global Fund and World Bank Booster Program, innovative financing mechanisms for malaria medicines and commitments by governments in endemic countries.

Despite a significant increase in global spending, we still fall far short of the true need which is at least US$3.2 billion for implementation and US$0.9 billion for research and development per annum. This need will increase significantly as we begin to consider sustained control and elimination.

Global policy changes include: investments in stronger health systems, breaking delivery bottlenecks at country level for critical interventions, shoring up the ACT pipeline, drug resistance, support for community-based care, technology development (diagnostic, treatment, prevention) and sustained financing (note: this list is illustrative, not exhaustive).

Your comment highlights the importance of public education and behavior change strategies. Having a bed net does not guarantee use and inconsistent use put individuals at risk.

Investments in operational research to understand facilitators and barriers to bed net use, public awareness and other educational campaigns to sensitize local communities to the need and benefits of personal protection. These strategies should be planned into programs as they are developed.

Remote communities are addressing missed malaria diagnoses by using community workers to identify symptoms and begin treatment. The benefit is that, many times, symptoms are in fact malaria and illness is avoided. The challenge is that malaria symptoms are similar to other infectious diseases so presumptive treatment may result in using medicines that could be used otherwise. It can lead to drug resistance over time. It can also leave children to suffer from the other, undiagnosed condition.

Community workers will benefit from additional training. It will also be helpful to make clinical tests (microscopy and RDTs) available in rural settings. This will require funding to increase the availability and reduce the cost of these diagnostics and health systems able to deliver and administer tests and treatment.

It is most realistic and beneficial to build capacity at the community level than to attempt to get all (or most) cases from remote areas to formal health settings for diagnosis and treatment.

Please see response to Dr.Bhudeb Sen Gupta for further comment.

In Fall 2007, "eradication" reemerged as a priority topic in global conversation. Global efforts began in the 1950s; they were abandoned in less than two decades with mixed results. This lesson from history highlights the fact that sustained malaria control, elimination and possibly eradication will require long-term commitments that the world has yet to demonstrate.

Malaria is a product of tropical environments. In those environments, eradication will be most challenging.

The road toward eradication involves the rapid scale-up of existing interventions. These efforts must be sustained over time and complemented with research to improve current tools and develop new ones. Health systems will need to be strengthened, programs monitored and revised and stakeholders mobilized for long-term advocacy and support.

Please see response to Lanre Olusegun Ikuteyijo.

Malaria costs the African continent US$12 billion each year in lost productivity. Is is more than a health challenge; it is in the economic interests of nations to address the disease.

At the national level, progress is being made in some countries to remove the barriers imposed by taxes and tariffs on bed nets and other commodities.

Civil society has a critical role to play in callling for the transparency and accountability of donors and national governments to ensure that pledged resources are allocated responsibly.

Please see earlier response regarding global spending and programming for malaria. Global financial commitments to malaria have never been higher. Now, the commitments must be sustained and well-programmed.

Regarding DDT, the WHO has issued guidance about its appropriate use and a number of countries are applying the guidance and using DDT in rotation with other insecticides. Insecticide rotation is critical to guard against resistance.

Remittances of almost $1 billion a day come from both legal and unauthorized migrants, but there is no way to know what share from from the unauthorized.

Good question with no easy answer. Competition is always tough, especially on businesses losing customers to visible “strangers.” Market-based economies work only if there are rules that are enforced to make the playing field level.

If the losers perceive the newcomers as illegitimate, as it sounds like they do in South Africa, the businesses losing customers can use anti-migrant arguments to protect their businesses, just as countries sometimes use food security as an argument to keep out cheaper food. The solution, which is not easy, is to ensure that the new competitors are legal and seen as having an equal right to compete.

Good questions. The US during the banana republic era intervened regularly in Latin America, creating resentment that makes most policy makers reluctant to try intervention again. The US government can certainly be supportive of democratic governments, but this becomes a very fine line.

Many countries have guest worker programs that aim to add workers to the labor force but not settlers to the population, and in all cases some guests become permanent residents, as with Turks in Germany. Canada has recently expanded its guest worker programs, so we don’t yet know if they will “work” as planned.

Rising productivity of Mexican workers should lead to higher wages, but it may take decades.

This is hard. Who has the responsibility for development—industrial nations or developing countries? Money flows to where it will be most likely to make a profit, not to where it is “needed,” and developing countries losing their best and brightest workers may not be attractive to investors, so that some migration can lead to more migration.

The solution to unwanted migration is development—the question is how we get development, and that is bigger than just migration.

Yes to most of these questions. Brain drain can make it harder for a country to develop, both because successful migrants encourage others to leave and because the absence of professional workers can discourage the investment needed for economic growth.

All the things that contribute to development—good government, peace, economic growth—etc help to keep people at home.

Developing Africa is a challenge for both African countries and their industrial country donors

There will always be migration, and some of it will be illegal, unauthorized, or irregular. Sending workers abroad can lead to virtuous and vicious circles at home. An example of a virtuous migration and development circle involved the sending Indian IT workers abroad in a manner that led to new industries and jobs and improved the quality of IT services throughout India. An example of a vicious migration and development circle may be the emigration of African doctors and nurses that reduces health care, especially in rural areas, making remaining workers less productive and slowing economic development.

NGOs are helping to make the world a better place in many aspects of life, including assisting migrants. More coordination is generally useful, so that their efforts can help the most people.

Getting guest workers to leave as programs require is always hard. Successful guest worker programs are likely to include economic incentives, such as return bonuses, not just rules that tell migrant workers they have to leave because their year or two is up.

Many of the reasons for Unauthorized Migration lie within the receiving countries, as when industrial countries make it hard for developing countries to send them farm products, but make it much easier for farm workers to enter and work illegally.

The US accepts about 3,500 legal immigrants a day, or 1.3 million a year, more than the rest of the world combined. Most Americans want immigration reduced. Determining how much the US is responsible for the conditions that lead to migration is very difficult.

Migrant remittances do reduce poverty, but they may not speed development. The key is to have sound economic policies in migrant-sending countries so that their remittances and returns contribute to development.

Especially in Chiapas, Mexico uses Guatemalan workers to work in agriculture. There is often 2-stage migration, as when Thais migrate to Taiwan to work in construction, and Burmese migrate to Thailand to fill construction and other jobs.

Many developing countries spend a great deal of their limited education budgets on higher education, even though graduates may not be able to find jobs. These countries may want to reduce subsidies for higher education and increase them for K-12 schools. In India and the Philippines, many tuition-charging private schools educate nurses and IT workers, so that taxpayers do not “lose” as much with emigration.

About 5 percent of the 150 million US workers are believed to be unauthorized, some 8 million. Most US businesses and consumers are not much affected by their presence. It is very hard to answer the common hypothetical of “what would happen if…” mostly because it would be impossible to quickly remove 8 million people.

The bigger question is what to do about the continuing influx of about 500,000 unauthorized a year. Until that is dealt with, there is not likely to be another legalization

There is lots of migration from one developing country to another, and this is one example.

Most countries do not have US-style birthright citizenship. The US grants citizenship to those born in the US, but does not allow children to sponsor their parents for immigrant visas until they turn 21.

There are certainly foreign students and others who have children while in the US, and whose children eventually return to the US and sponsor their parents’ admission. However, it is very hard to obtain reliable data on how often US-born children sponsor their parents 21 years later, and what costs (if any) these parents impose on US taxpayers.

More common is the case of an immigration enforcement action that discovers families with unauthorized parents and US-born children. The parents are deportable, but not the US-born child, forcing decisions about whether to leave the child in the US or take the child back to the parents’ country of origin. Some parents who say they came to the US illegally to give their children a better life leave their children in the US, or appeal to stay because, they say, their children would not have appropriate medical care etc at home.

These are tough cases with no easy answers, but they do highlight an important difference between trade and migration, as when some people say that in a globalized world with freer trade, there should also be freer migration. Unlike goods, people reproduce.

Most people agree that a key to reducing unauthorized migration is closing the labor market door to illegal workers. Northern European countries such as Sweden do this much better than the US, as do Singapore, Japan, and many other industrial countries. Countries such as Italy and Spain that are less able to regulate the informal economy and labor market have periodic amnesties for unauthorized workers.

This is a hard one. It is much easier to say that there are 8 million unauthorized workers than to say that job X would be filled by a US worker if there was one fewer unauthorized.

One way to think about the interaction of legal and illegal workers is to think about networks—you get a job because you have a friend or relative already working there who tells you about it. Most jobs in agriculture, meatpacking, janitorial services and other industries that employ unauthorized migrants are filled via such networks, and as long as new unauthorized migrants continue to arrive, there is no need to search for US workers, raise wages, make the work easier etc.

This is what seems to have happened in some parts of the US labor market. US workers are not likely to rush into “unauthorized jobs” as they are currently structured and paid, but might if wages and working conditions changed. As wages rose, employers might figure out how to get the work done with fewer workers as well.

I assume you mean the demographic transition from high birth rates and high death rates to low birth rates and low death rates. Developing countries in stage 2 or stage 3 have lots of people turning working force age each year. If these countries can employ these extra workers, they can get a demographic dividend that accelerates their economic growth, as in the Asian tiger economies that attracted foreign investment and became export powerhouses. If they cannot, as in Mexico and many other developing countries, emigration pressures can increase.

I do not know—I assume that, with immigrants and their US-born children accounting for most US population growth, and most immigrants coming from Latin America, the Philippines, and other Catholic countries, the ratio of Catholics to Protestants would rise.

Immigrants have a higher fertility rate than the US-born population and they are relatively young, in the child-bearing years, so the percentage of births to foreign-born women is higher than their share of US residents.

About 24 percent of the 4.1 million US births in 2004 were to immigrant women, and 63 percent of births to Hispanic mothers were women born outside the US. www.cdc.gov/nchs/products/pubs/pubd/nvsr/nvsr.htm

Thanks, UN Conventions distinguish smuggling, where the client pays for a service, and trafficking, where there is coercion and a victim. It is often hard to draw a firm line between the two, since what begins as a migrant hiring a smuggler can turn into trafficking if the migrant is held to pay of the smuggling debt etc.

Because of this slipperiness, there are lots of estimates of how much trafficking occurs. In general, there appears to be far less trafficking in the US than is sometimes reported—see http://migration.ucdavis.edu/mn/more.php?id=3317_0_2_0

For more on this

Trafficking is defined as holding someone through force, fraud or coercion for sex or other work. Between 2000 and 2007, the US government has spent more than $500 million to combat trafficking, with 10 federal agencies reporting on their anti-trafficking efforts to a Cabinet-level task force chaired by Secretary of State Condoleezza Rice. Much of the anti-trafficking money was given as grants to groups that seek to educate trafficking victims about their rights.

By 2006, the estimated number of people trafficked into the US was reduced to 14,500 from 17,500 a year. The anti-trafficking effort continues, in part because of a confluence of interest between Christian and feminist groups. Newly formed groups receiving federal funds educate local police and hospitals about how to identify and treat victims of trafficking.

I don't think the critical question is whether it's totally public-funded or not. I think the critical question is whether a given sanitary system actually works to provide clean water and safely remove sewage, whether it is maintained and operationally sustainable, whether it responds to the real needs of people at highest risk of water-borne diseases (e.g. the poorest) or serves only those who are better off. In many instances, this will indeed be mostly or totally public-funded, but the devil is in the details. The ways in which a working sanitary system improves child health is in the reduction of water-borne diseases, notably diarrheal diseases which still claim 2 million lives a year, and which account for a massive impact on undernutrition.

Firstly, the Global Health Council defines "low income" as people living on less than $2 per day (roughly 2.5 billion people). These are the people at highest risk of child mortality and morbidity, and they are our stated priority. Clearly those living at the lowest end of this scale will benefit most from the broad and proven cost-effective approaches to the most common childhood killers -- childhood immunization, oral rehydration therapy for diarrhea, case management of pneumonia and malaria, vitamin A supplementation, and basic nutritional education and support. However, these programs do not significantly address the 40% of childhood deaths which occur in the perinatal and neonatal period; these require stronger systems for maternal and birth care and rapid response to early signs of neonatal problems. While these approaches are still quite basic, they require a level of infrastructure and health systems capability that may be more readily applied in middle-low income and higher settings.

I would challenge the presumption that any single approach is the "best long term solution." What is needed is a systemic, and systematic solution that recognizes there is a spectrum of issues that need to be addressed. That said, family planning is indeed a vitally important contributor to improving child health and reducing child mortality. We know that increased child spacing and reduction in family size has a direct and very positive impact on child health and survival, as well as on nutritional status of children and their mothers, and on the prospects for education and economic opportunity. But let's not imagine that we can reduce by two-thirds the nearly 10 million under-five deaths through family planning and reproductive health care alone. For that, we need simple but integrated programs that also work to address the leading causes of child illness and death, delivered in the same clinics and programs that are providing RH care to the mothers.

Without a doubt, a critical determinant of the health of children is the underlying health of their mothers. If they are well nourished and have the opportunity to space and limit their pregnancies according to their own family needs and wishes, their children will have a higher likelihood of surviving and growing up healthy. However, materhal health alone will not resolve the enormous burden of childhood disease. Malaria-carrying mosquitoes will continue, whatever maternal health status. Poor sanitation will continue to make diarrhea a major killer. The area where maternal health care has the greatest potential to impact the health of children is in care of HIV-positive mothers, not only to prevent the transmission of HIV to their newborns, but also to assure the health and survival of the mothers upon whom these children depend for their own survival.

Join the Global Health Council, come to the annual international conference on global health in Washington, DC in the end of May, meet with as many health practitioners and implementers there as you can, work toward an opportunity to serve the poor in low-income countries so that you can gain a first-hand experience that goes beyond first impressions, and THEN figure out where you might be able to provide a critical input -- either in direct service, in critical areas of research, or in support for advocacy efforts to direct attention and resources to the critical health needs of the world's poorest citizens. You can find more at www.globalhealth.org.

Of course you are correct. Child marriage is bad for the girl, bad for the children she has before she is fully ready to be a mother, and bad for societies. It is a widely practiced and sadly accepted form of extreme child abuse and should be fought by legal means and changes in cultural norms. This shows that the answer to issues of child health are about more than just medical interventions. We must also look at, and respond to, the social determinants. However, all children, even those of mothers who are themselves children, benefit from essential child health services, and we should not wait for society to make the changes that are needed before we respond to the very immediate health needs of the children.

It depends very much on the patterns of child death. In very low income societies, a considerable proportion of all child deaths -- sometimes as much as one half -- takes place in children between the ages of 12 and 59 months. In these situations, addressing the leading causes of death among these somewhat older children is often the quickest and easiest way to begin to lower childhood mortality. You can find more information on our website at www.globalhealth.org/childhealth. As a rule, death rates decrease dramatically above the age of 5, so older children are not a major focus of efforts. However, in most instances, it is children less than a year of age (infants) who suffer the largest proportion of child deaths, and in those instances it is appropriate to focus on their needs and health determinants. As noted in another question, addressing the health needs and survival of neonates is the largest piece of the "unfinished agenda" of child health, and should be addressed when the fundamental and inexpensive interventions addressing immunizable and readily treatable diseases are on the way to being handled.

I'm afraid you are asking a question best answered by a health economist; I am just a doctor. Clearly, we need ways to finance essential health services for poor children, who cannot themselves pay for anything, and whose families are often unable to pay for services. My personal view is that a package of essential child health services should be made universally available at no cost to those in need. That way we avoid market barriers as determinants of unnecessary illnesses and deaths, and ultimately this contributes to healthier, more productive, and ultimately more affluent societies. However, since many of these societies are very poor, this is why external support is critical to move past this conundrum, and the reason that the Global Health Council has called for affluent countries to invest an additional $7 billion a year (with $2 billion of that from the U.S) in maternal and child health programs in the world's poorest countries (see our analysis at http://www.globalhealth.org/child_health/needs_costs/.

1. We are seeing improvement. If we had not had child health and survival programs that started in the 1980s, we would today be experiencing more than 16 million child deaths a year. For the first time IN HISTORY this year, child deaths fel