Bhutta – social determinants

The big picture in countries like mine is that: of every thousand children born in my country, roughly about a hundred will not live to see their fifth birthday; and of those a large majority close to around sixty, will actually die in the first four weeks of life, many within the first few days. So, the imperatives of working on issues of child survival, newborn survival in developing countries such as mine necessitated a change in tactics.  

OK. So, one was to look at the context of the major challenges of maternal newborn and child survival in Pakistan as in the most of the developing world where the burden is maximum. There are several things that come to the fore: one is that it is bigger than a health issue because if you look at social determinants of health, there is a very close relationship of maternal newborn and child mortality with simple factors like: maternal education, women’s empowerment, social structures, poverty, distance, access to health services and so on and so forth. 

In terms of distance many people ask me: are all of these, adverse outcomes, mortality rate, clustered in the remotest parts of the country? The answer is no. If you are poor and have very little access to services or social barriers, five kilometres can be as long as five hundred kilometres. 

So, there are a lot of underpinnings of adverse health outcomes that one should be very aware of. So, in our own work around maternal newborn and child survival, we have specifically focused on understanding the determinants, some of the immediate causes, looking at the evidence base of what works and how best to implement what works. So, a large portion of work has been around the implementation strategies to make things happen at community level, using low level health workers, community delivery platforms.  

Now, as we get into saving lives for families and communities one big question is saving lives for what outcome? To saving a life of a child in a newborn period only for the child to die six months later due to diarrhoea is quite a meaningless exercise, to save the life of a six months old child from something like diarrhoea and pneumonia only for that child to die from another disease in a year or two years time again is questionable. To save all of these children only for them to develop polio at five years of age is also a travesty, so increasingly we became aware of the importance of linking survival with quality of life; and when you come to quality of life immediately it becomes very clear that one has to look at a lot of determinants of physical, mental, nutritional, long term outcomes, things that actually go way beyond the childhood period and hence you begin to think of the entire outcomes of maternal and child health in developmental terms. So, we began to realize in our own work that it was very myopic to just focus on saving lives even though it became a very important consideration and precisely for this reason we diverted a lot of our resources and attention to number one, understanding the link between survival and quality of life.