- Email: [email protected]
A new leadership for UNICEF: do values matter?
Correspondence
words. In a press release from Sida in June, 1997, 3 years after the first democratic election, lack of political will on the part of the government was stated to be a reason for disengagement. Obviously, for Sida, Guinea-Bissau was not a qualified partner. Before the full-scale withdrawal of Sida from Guinea-Bissau, other forces came into play. In June, 1998, a military uprising in Bissau broke out. After a peace accord was established a year later, in which the Swedish chargé d’affaires had an important role, Sida moved its headquarters to the more metropolitan Dakar in Senegal. Still serving the poor, Sida gave assistance to alleviate the debt burden of GuineaBissau. Funds were also provided to rebuild the physical structures of LNSP after one of the last bombs that struck Bissau during the war left it in ruins. How can we address the problems facing countries characterised by instability and bad governance? These countries have the highest child mortality rates in the world. Development organisations opt out of such countries, preferring those with higher so-called aid absorption capacity and supposed higher probability of effectiveness. Further, countries that do not conform to the one-size-fits all approach of donors fall out of favour. Their populations become doubly damned—first for living in conditions of bad governance, and second for being denied aid for just the same reason. Without international support to strengthen health-care services and education, mothers in poor countries will continue to weep over the death of their children.5 We declare that we have no conflict of interest.
*Jónína Einarsdóttir, Geir Gunnlaugsson [email protected] *Department of Anthropology and Folkloristic, Oddi v/Sturlugötu, University of Iceland, IS-101 Reykjavík, Iceland (JE); and Centre for Child Health Services, Reykjavík, Iceland (GG) 1
1136
Horton R. UNICEF leadership 2005–2015: a call for strategic change. Lancet 2004; 364: 2071–74.
2 3
4
5
King M. Health is a sustainable state. Lancet 1990; 336: 664–67. Scheper-Hughes N, ed. Child survival: anthropological perspectives on the treatment and maltreatment of children. Dordrecht: D Reidel Publishing Company, 1987. Thorbecke E. The evolution of the development doctrine and the role of foreign aid, 1950-2000. In: Tarp F, ed. Foreign aid and development. Lessons learnt and directions for the future. London: Routledge, 2000: 17–47. Einarsdóttir J. Tired of weeping: mother love, child death, and poverty in Guinea-Bissau, 2nd edn. Madison: University of Wisconsin Press, 2004.
A new leadership for UNICEF: do values matter? The United Nations Children’s Fund (UNICEF) aspires to be “the driving force that helps build a world where the rights of every child are realized”.1 This year’s State of the World Children is dedicated to three key threats affecting more than one billion children: poverty, armed conflicts, and HIV/AIDS. The causes are complex and interlinked and must be fought to ensure the rights of the children. We think that the recent appointment of Ann Veneman as the next Executive Director of UNICEF will hinder this fight. Veneman is a political conservative who has served under Republican administrations dating back to President Reagan and was the Secretary of Agriculture during the first term of the Bush administration. In recent years, US agricultural liberalisation policies have promoted a model based on countries specialising in what they are best at producing, exporting these products, and relying on foreign exchange earnings to purchase other food for local consumption. This model contrasts sharply with one of self-sufficiency, which tries to ensure that domestic food requirements are met from local production to guarantee food security.2 Another controversial international agricultural issue involves the subsidies that rich countries provide their
farmers for export-oriented products. These subsidies have led to food being exported to developing-country markets at prices that undermine local food production. Legislation in the USA approved in 2002 increased agricultural subsidies by 80% over their 1996 levels, granting more than US$180 billion to support US producers over the next 10 years. These subsidies, nevertheless, do not tend to reach small producers in the USA, but mostly larger landowners. In Mexico, these policies have affected the livelihoods of more than 2·5 million corn producers. In Peru, thousands of small cotton producers have had to drastically reduce their cultivation, while cotton imports, most of which are of US origin, abruptly grew 284% in 2002. At the same time, the US agribusiness giants have seen substantial earnings gains.3,4 These policies are resulting in an increase in inequality and poverty among the marginalised. Veneman has already stated that she is not interested in a broad social agenda and declared that she wants to fight malnutrition.5 We can be sure it will not be by challenging the agricultural politics she represents. UNICEF needs an independent leader with strong values based on children’s rights as well as experience in child health. It is a tragic development for the UN if the rights of children have to be compromised in order to smooth its relationship with the US administration. We declare that we have no conflict of interest.
*Miguel San Sebastian, Anna-Karin Hurtig [email protected] Umeå International School of Public Health, Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine, Umeå University, SE-901 85 Umeå, Sweden 1
2
UNICEF. About UNICEF: who we are. http://www.unicef.org/about/who (accessed Jan 3, 2005). Food and Agriculture Organization. Declaration of the World Summit: 5 years later. http://www.fao.org/DOCREP/ MEETING/004/ Y6948E.HTM (accessed Feb 17, 2005).
www.thelancet.com Vol 365 March 26, 2005
Correspondence
3
4
5
Oxfam. Make trade fair for the Americas: agriculture, investment and intellectual property: three reasons to say no to the FTAA. http://www.oxfam.org.uk/what_we_ do/issues/trade/bp37_trade_americas.htm (accessed Jan 3, 2005). San Sebastián M, Hurtig AK. From NAFTA to FTAA? The impact of deregulation of trade on social and health conditions of people of the Americas. Pan Am J Public Health 2004; 16: 272–78. Pisik B. Annan taps Veneman to head UNICEF. Washington Times. Jan 19, 2005. http:// www.washtimes.com/world/20050118095602-8058r.htm (accessed Feb 17, 2005).
Repeat sudden unexpected infant deaths The series of repeat sudden infant deaths presented by Robert Carpenter and colleagues (Jan 1, p 29)1 is the largest yet reported, and the data are especially valuable in an area where there is a dearth of good evidence. In reaching their conclusions, however, the authors may not have taken sufficient account of two possible sources of bias. First, self-selection at two stages raises the possibility that the sample studied was not a true cross-section of sudden infant deaths. The Care of the Next Infant (CONI) programme, from which the cases were drawn, is voluntary, and the numbers and characteristics of non-participants are unknown. Then, of the 46 participating families who had a repeat unexpected death, 13 (28%) were not subject to full enquiry, seven because they declined. Carpenter and colleagues acknowledge these difficulties but do not adequately allow for them. The second and more serious problem is the scope for bias in decisions as to whether a death was natural or unnatural. Recognition of covert homicide in infancy is notoriously difficult: the history may be fictitious and the autopsy unhelpful, and there are no agreed diagnostic criteria.2 Thus, judgments have to be largely subjective, and sometimes it is simply not possible to be certain. Several of the cases attributed to sudden infant www.thelancet.com Vol 365 March 26, 2005
death syndrome (SIDS) in this paper have features that, in the context of two unexplained deaths, must give rise to concern: violence in the family (nine cases), parental mental health problems (six), preceding apparent life-threatening events (three), postmortem findings suggestive of asphyxia (nine), abuse of a previous child (one), open coroner’s verdict (three), and professional concern about the safety of other children (four). Instead of dichotomising the cases into natural or unnatural, it would have been more accurate (although less tidy) to have a third category—a grey area in which it was not possible to be certain. The potential fallibility of the categorisations in this study is illustrated by the initial designation of two deaths in one family as natural, with a later change to unnatural when the father admitted killing a third baby. The investigators seem to have taken the benign view that a death should be classified as natural unless there was compelling evidence to the contrary—an approach that is appropriate in the courts but not in scientific debate. Distinction between the legal and scientific arenas is crucial. In law, a person is presumed innocent until proved guilty beyond reasonable doubt. In scientific debate, presumption and benignity have no place: all possibilities compatible with the evidence have to be considered dispassionately. This paper will be influential, but those quoting it should be aware that its data do not support such clear-cut conclusions. Until we have more reliable means of identifying covert homicide, we cannot be certain of the proportion of repeat sudden infant deaths that is unnatural. It may well be rather higher than this analysis suggests. I declare that I have no conflict of interest.
Christopher Bacon [email protected] Glebe House, Danby Wiske, Northallerton DL7 0LY, UK
1
2
Carpenter RG, Waite A, Coombs RC, et al. Repeat sudden unexpected and unexplained infant deaths: natural or unnatural? Lancet 2005; 365: 29–35. Levene S, Bacon CJ. Sudden unexpected death and covert homicide in infancy. Arch Dis Child 2004; 89: 443–47.
Robert Carpenter and colleagues1 imply that I advocate ruling multiple infant deaths in a family as homicide solely on the basis of statistical probabilities. I would suggest that they reread the sections of my book dealing with infanticide, SIDS, and how to approach a forensic case.2 Aside from it being bad medicine, I would not make rulings solely on the basis of statistics for two reasons. First, I am not a statistician and judge it inappropriate to practise outside my area of expertise of forensic pathology. Second, statistical data in the area of SIDS and infanticide by smothering are unreliable. Carpenter and colleagues, who are epidemiologists and paediatricians, seem not to be disturbed by venturing outside their area of expertise and using dubious data. The basic fact that they fail to comprehend is that the diagnosis of SIDS actually means that one does not know why a child has died. It is a “wastebasket” diagnosis. Most such deaths are probably due to a natural disease of some sort, with some due to overlay (ie, accidental suffocation or crushing as a result of bed sharing) and others to asphyxia by deliberate smothering. Carpenter and colleagues refer to 40 deaths as “natural” but seem to include in this category cases in which overlay may have occurred. The prose is somewhat murky to say the least and I had difficulty understanding what cases belonged in which category. Additionally, they include in this number cases for which a natural cause of death was determined. These cases would not be regarded as second or third unexplained deaths to a forensic pathologist because the cause of death was known. In attributing most of the 40 deaths to SIDS, Carpenter and colleagues are essentially saying they have a group of 1137
words. In a press release from Sida in June, 1997, 3 years after the first democratic election, lack of political will on the part of the government was stated to be a reason for disengagement. Obviously, for Sida, Guinea-Bissau was not a qualified partner. Before the full-scale withdrawal of Sida from Guinea-Bissau, other forces came into play. In June, 1998, a military uprising in Bissau broke out. After a peace accord was established a year later, in which the Swedish chargé d’affaires had an important role, Sida moved its headquarters to the more metropolitan Dakar in Senegal. Still serving the poor, Sida gave assistance to alleviate the debt burden of GuineaBissau. Funds were also provided to rebuild the physical structures of LNSP after one of the last bombs that struck Bissau during the war left it in ruins. How can we address the problems facing countries characterised by instability and bad governance? These countries have the highest child mortality rates in the world. Development organisations opt out of such countries, preferring those with higher so-called aid absorption capacity and supposed higher probability of effectiveness. Further, countries that do not conform to the one-size-fits all approach of donors fall out of favour. Their populations become doubly damned—first for living in conditions of bad governance, and second for being denied aid for just the same reason. Without international support to strengthen health-care services and education, mothers in poor countries will continue to weep over the death of their children.5 We declare that we have no conflict of interest.
*Jónína Einarsdóttir, Geir Gunnlaugsson [email protected] *Department of Anthropology and Folkloristic, Oddi v/Sturlugötu, University of Iceland, IS-101 Reykjavík, Iceland (JE); and Centre for Child Health Services, Reykjavík, Iceland (GG) 1
1136
Horton R. UNICEF leadership 2005–2015: a call for strategic change. Lancet 2004; 364: 2071–74.
2 3
4
5
King M. Health is a sustainable state. Lancet 1990; 336: 664–67. Scheper-Hughes N, ed. Child survival: anthropological perspectives on the treatment and maltreatment of children. Dordrecht: D Reidel Publishing Company, 1987. Thorbecke E. The evolution of the development doctrine and the role of foreign aid, 1950-2000. In: Tarp F, ed. Foreign aid and development. Lessons learnt and directions for the future. London: Routledge, 2000: 17–47. Einarsdóttir J. Tired of weeping: mother love, child death, and poverty in Guinea-Bissau, 2nd edn. Madison: University of Wisconsin Press, 2004.
A new leadership for UNICEF: do values matter? The United Nations Children’s Fund (UNICEF) aspires to be “the driving force that helps build a world where the rights of every child are realized”.1 This year’s State of the World Children is dedicated to three key threats affecting more than one billion children: poverty, armed conflicts, and HIV/AIDS. The causes are complex and interlinked and must be fought to ensure the rights of the children. We think that the recent appointment of Ann Veneman as the next Executive Director of UNICEF will hinder this fight. Veneman is a political conservative who has served under Republican administrations dating back to President Reagan and was the Secretary of Agriculture during the first term of the Bush administration. In recent years, US agricultural liberalisation policies have promoted a model based on countries specialising in what they are best at producing, exporting these products, and relying on foreign exchange earnings to purchase other food for local consumption. This model contrasts sharply with one of self-sufficiency, which tries to ensure that domestic food requirements are met from local production to guarantee food security.2 Another controversial international agricultural issue involves the subsidies that rich countries provide their
farmers for export-oriented products. These subsidies have led to food being exported to developing-country markets at prices that undermine local food production. Legislation in the USA approved in 2002 increased agricultural subsidies by 80% over their 1996 levels, granting more than US$180 billion to support US producers over the next 10 years. These subsidies, nevertheless, do not tend to reach small producers in the USA, but mostly larger landowners. In Mexico, these policies have affected the livelihoods of more than 2·5 million corn producers. In Peru, thousands of small cotton producers have had to drastically reduce their cultivation, while cotton imports, most of which are of US origin, abruptly grew 284% in 2002. At the same time, the US agribusiness giants have seen substantial earnings gains.3,4 These policies are resulting in an increase in inequality and poverty among the marginalised. Veneman has already stated that she is not interested in a broad social agenda and declared that she wants to fight malnutrition.5 We can be sure it will not be by challenging the agricultural politics she represents. UNICEF needs an independent leader with strong values based on children’s rights as well as experience in child health. It is a tragic development for the UN if the rights of children have to be compromised in order to smooth its relationship with the US administration. We declare that we have no conflict of interest.
*Miguel San Sebastian, Anna-Karin Hurtig [email protected] Umeå International School of Public Health, Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine, Umeå University, SE-901 85 Umeå, Sweden 1
2
UNICEF. About UNICEF: who we are. http://www.unicef.org/about/who (accessed Jan 3, 2005). Food and Agriculture Organization. Declaration of the World Summit: 5 years later. http://www.fao.org/DOCREP/ MEETING/004/ Y6948E.HTM (accessed Feb 17, 2005).
www.thelancet.com Vol 365 March 26, 2005
Correspondence
3
4
5
Oxfam. Make trade fair for the Americas: agriculture, investment and intellectual property: three reasons to say no to the FTAA. http://www.oxfam.org.uk/what_we_ do/issues/trade/bp37_trade_americas.htm (accessed Jan 3, 2005). San Sebastián M, Hurtig AK. From NAFTA to FTAA? The impact of deregulation of trade on social and health conditions of people of the Americas. Pan Am J Public Health 2004; 16: 272–78. Pisik B. Annan taps Veneman to head UNICEF. Washington Times. Jan 19, 2005. http:// www.washtimes.com/world/20050118095602-8058r.htm (accessed Feb 17, 2005).
Repeat sudden unexpected infant deaths The series of repeat sudden infant deaths presented by Robert Carpenter and colleagues (Jan 1, p 29)1 is the largest yet reported, and the data are especially valuable in an area where there is a dearth of good evidence. In reaching their conclusions, however, the authors may not have taken sufficient account of two possible sources of bias. First, self-selection at two stages raises the possibility that the sample studied was not a true cross-section of sudden infant deaths. The Care of the Next Infant (CONI) programme, from which the cases were drawn, is voluntary, and the numbers and characteristics of non-participants are unknown. Then, of the 46 participating families who had a repeat unexpected death, 13 (28%) were not subject to full enquiry, seven because they declined. Carpenter and colleagues acknowledge these difficulties but do not adequately allow for them. The second and more serious problem is the scope for bias in decisions as to whether a death was natural or unnatural. Recognition of covert homicide in infancy is notoriously difficult: the history may be fictitious and the autopsy unhelpful, and there are no agreed diagnostic criteria.2 Thus, judgments have to be largely subjective, and sometimes it is simply not possible to be certain. Several of the cases attributed to sudden infant www.thelancet.com Vol 365 March 26, 2005
death syndrome (SIDS) in this paper have features that, in the context of two unexplained deaths, must give rise to concern: violence in the family (nine cases), parental mental health problems (six), preceding apparent life-threatening events (three), postmortem findings suggestive of asphyxia (nine), abuse of a previous child (one), open coroner’s verdict (three), and professional concern about the safety of other children (four). Instead of dichotomising the cases into natural or unnatural, it would have been more accurate (although less tidy) to have a third category—a grey area in which it was not possible to be certain. The potential fallibility of the categorisations in this study is illustrated by the initial designation of two deaths in one family as natural, with a later change to unnatural when the father admitted killing a third baby. The investigators seem to have taken the benign view that a death should be classified as natural unless there was compelling evidence to the contrary—an approach that is appropriate in the courts but not in scientific debate. Distinction between the legal and scientific arenas is crucial. In law, a person is presumed innocent until proved guilty beyond reasonable doubt. In scientific debate, presumption and benignity have no place: all possibilities compatible with the evidence have to be considered dispassionately. This paper will be influential, but those quoting it should be aware that its data do not support such clear-cut conclusions. Until we have more reliable means of identifying covert homicide, we cannot be certain of the proportion of repeat sudden infant deaths that is unnatural. It may well be rather higher than this analysis suggests. I declare that I have no conflict of interest.
Christopher Bacon [email protected] Glebe House, Danby Wiske, Northallerton DL7 0LY, UK
1
2
Carpenter RG, Waite A, Coombs RC, et al. Repeat sudden unexpected and unexplained infant deaths: natural or unnatural? Lancet 2005; 365: 29–35. Levene S, Bacon CJ. Sudden unexpected death and covert homicide in infancy. Arch Dis Child 2004; 89: 443–47.
Robert Carpenter and colleagues1 imply that I advocate ruling multiple infant deaths in a family as homicide solely on the basis of statistical probabilities. I would suggest that they reread the sections of my book dealing with infanticide, SIDS, and how to approach a forensic case.2 Aside from it being bad medicine, I would not make rulings solely on the basis of statistics for two reasons. First, I am not a statistician and judge it inappropriate to practise outside my area of expertise of forensic pathology. Second, statistical data in the area of SIDS and infanticide by smothering are unreliable. Carpenter and colleagues, who are epidemiologists and paediatricians, seem not to be disturbed by venturing outside their area of expertise and using dubious data. The basic fact that they fail to comprehend is that the diagnosis of SIDS actually means that one does not know why a child has died. It is a “wastebasket” diagnosis. Most such deaths are probably due to a natural disease of some sort, with some due to overlay (ie, accidental suffocation or crushing as a result of bed sharing) and others to asphyxia by deliberate smothering. Carpenter and colleagues refer to 40 deaths as “natural” but seem to include in this category cases in which overlay may have occurred. The prose is somewhat murky to say the least and I had difficulty understanding what cases belonged in which category. Additionally, they include in this number cases for which a natural cause of death was determined. These cases would not be regarded as second or third unexplained deaths to a forensic pathologist because the cause of death was known. In attributing most of the 40 deaths to SIDS, Carpenter and colleagues are essentially saying they have a group of 1137