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Kalyan Bagchi and Ghada Hafez

 Child health strategies in the past two or three decades have produced significant results in bringing down infant and child mortality in most developing countries. However, this does not imply that infants and children who escape death attain their health potentials and enjoy their rights as enshrined in the Convention on the Rights of the Child. Evidence of newly emerging problems affecting children's physical, mental and emotional health are being constantly made available. There is a need for a fresh look at child health from a holistic viewpoint.

 At the World Summit for Children in September 1990, in the presence of many presidents and prime ministers, an assembly of national dignitaries never witnessed before promised joy and hope to millions of children whose life_if they live that long_is marked by denial of all types of basic rights enshrined in the Convention on the Rights of the Child. They have no access to education, recreation, adequate diet and even a roof over their head. The harshest example of such denial is the presence of millions of street children in most megacities and towns, whose miserable lives have suffered great abuse. Books have been written and films made about them to worldwide acclaim. But has their quality of life improved since the Convention's signing? There is no specific information about the health of these totally deprived children since they do not come under recorded statistics.

 While on the one hand there is general satisfaction that several strategies for child health promotion have shown significant achievements, an oft repeated question is "What happens to the children who escape, through the child survival strategy, the clutches of death?" Do they eventually achieve their growth and development potentials? The increasing number of issues that make attainment of adequate child health extremely difficult have made the international community ponder and look inwards. The need for a fresh look is obvious.

 The Family and Community Health Unit of WHO's Regional Office for the Eastern Mediterranean (EMRO) convened a scientific group meeting in Beirut, Lebanon, between 8 and 10 November 1994. The meeting was attended by child health experts from Bahrain, Egypt, the United Kingdom, the Libyan Arab Jamahiriyah, Sudan, Turkey and the United Arab Emirates. The technical secretariat was provided by EMRO and UNICEF; representatives from USAID (Egypt), UNHCR and UNDP (Lebanon) also participated.

 The experts at the meeting deliberated on the present state of child health. Progress in the area has been significant: the child health strategy in most countries has undoubtedly saved millions of infants and children from untimely death, and infant mortality and under five mortality levels are showing consistent downward trends. The nutritional status of infants and young children in the countries of the Eastern Mediterranean Region (EMR) has shown improvement except in countries and regions within countries that have been devastated by armed conflicts for long periods. It is tragic that in the armed conflicts and wars of today, civilians and not the armed forces are the victims, and among the civilian population, children are the major sufferers. Today millions of children are victims of malnutrition, infection, emotional trauma and abuse, including their forceful induction as "child soldiers" in some areas. The health sectors are helpless spectators in these situations, only providing humanitarian services if requested.

 Most countries in this Region are on the verge of achieving the mid decade goals set by WHO and UNICEF, among which the achievements in controlling vaccine-preventable diseases in children are remarkable. The time is not far off when polio will be eliminated from the face of the earth. With concerted action and political commitment, other diseases like measles, tetanus and diphtheria will gradually cease to be public-health problems for children. The nutritional status of infants and children has also shown significant improvement. The florid cases of protein-energy malnutrition like kwashiorkor are rarely encountered in normal situations. Even the prevalence of severe cases of child malnutrition is very much less in all countries. However, chronic energy deficiency in children is still a problem of concern along with continued damage from micronutrient malnutrition.

 The most remarkable achievement spearheading child health programmes in the past two decades has been the social mobilization leading to political commitment at the highest levels. Advocacy for child health has been mounted at impressive levels by several international and bilateral agencies and nongovernmental organizations with remarkable impact. In the past twenty years we have witnessed with great satisfaction the tremendous use of mass media, especially television and video, in vigorous social marketing campaigns for the promotion of child health. Other accomplishments are the evolution and refinement of managerial skills in planning and implementing health programmes. This, coupled with development of infrastructure and a critical mass of trained workers, has undoubtedly been a major underlying cause for the attainment of child health promotion measures. Any future plan of action must consolidate these strategies with more vigour.

 This is more so in view of the worldwide economic recession, which is hitting the developing countries most and leading to structural adjustments in national development processes; education and health care are the usual victims. In the financially constrained health sector, health care is often bypassed with preference given to the establishment of hospitals. There are instances where previously child survival was given high priority but now development is being diluted in many cases as identification of new priorities occurs, conforming to a shift of donor emphasis.

 What is needed in child health programmes in future is a vigorous attempt to consolidate earlier achievements to ensure technical sustainability and an enlargement of scope to cover newly emerging problems, which are rarely included in conventional child health programmes. Childhood obesity due to a distorted diet and lifestyle among an economically affluent population, leading to other disorders in later life like non-insulin dependent diabetes, is already raising ugly heads in the Gulf countries and among the richer segments of population in other countries. Similarly, hereditary and genetic disorders of considerable prevalence, with consanguineous marriage as a precipitating factor, has yet to attract attention. Genetic counselling is still a rare service in routine Maternal and Child Health programmes in most countries.

 A matter of greatest concern is the steeply rising denial of children's rights through various derogatory practices, each of which has considerable health implications; but the health sector in most cases is a helpless spectator. Without political commitment at the highest national level and without very active collaboration of other sectors these problems will continue to exist in the world. The most glaring example of flagrant denial of rights of children is their use as child labour, which take various forms. Recent estimates made by the International Labour Organisation (ILO) and the Economic and Social Council of the United Nations indicate that millions of children in the world_both developing and developed_are exploited for their labour, the major reason being poverty of their parents and care givers. Malnutrition, poor health status and health disorders due to occupational hazardous work are the common profiles of these children. The problem of street children, their close links with sexually transmitted diseases, including AIDS, and their forced involvement in drug abuse and child prostitution are major child health problems today over which the health sector has no major control. Needless to say, countries that have ratified the Convention of the Rights of the Child will have to take on these issues with the highest priority before the problem goes beyond control. Indeed, child health issues need a fresh look and a strengthened strategy of a much wider scope.