Times of crisis are also times of opportunity. Much has been written about the unique opportunity that the Covid-19 pandemic offers to ‘build back better’, although precisely what this means is often not well defined. Will the world merely revert to the economic models that have dominated policy for so many decades, despite their inadequacy? Will the inequities in our societies, exposed and widened by the pandemic, be papered over? Or will the impetus of recovery from Covid-19 be used to devise new economic and social justice models which are fairer and representative of the contributions of those upon whom our future health, wellbeing and prosperity depend?
Answering these questions requires clear recommendations to governments, policy-makers, and other actors. This was the agenda of the thirty or so academics from the biomedical, social science and economic sectors who met representatives from international non-governmental organisations virtually in Venice over three days in March 2021 (The Venice Forum1). They have a clear message: there is an urgent need to assemble the case for improving population health by strengthening the health of mothers and young children, and in so doing build economic resilience and a sustainable future. Here we explain this message and its strong scientific, social justice and economic justifications. Future articles will describe the rationale and actions in greater detail.
Why the urgency? In large part, it arises from sobering statistics that were beginning to surface before the pandemic, showing that since 2014 average life expectancy in the US is falling. This means that for the first time since records began American children can expect to live shorter lives than their parents. The major cause of this extraordinary phenomenon is the relentless rise in the number of people with chronic non-communicable physical and mental diseases. The US is not alone in this respect as such diseases now account for about 70% of deaths globally each year. But as Anne Case and Angus Deaton, economists at Princeton show, the rise in mortality in the US has been especially stark for white men without college degrees. They describe these as “deaths of despair”, often from suicide and the consequences of drug and alcohol abuse. It is hardly surprising that poverty, lack of education and opportunity, unhealthy diet and lifestyle and low access to healthcare intersect to create despair. However, the “despair” that drives these behaviours is also a facet of the determinants of poor physical and mental health that are amplified across generations, leading to ever wider health and economic inequity and societal instability.
Once developed, chronic diseases such as many cardiovascular and lung conditions, diabetes, and some mental illnesses, are incurable, leading to a lifetime of dependency upon treatments and therapies. Worse still, the non-communicable diseases increase susceptibility to infectious diseases, as has been only too apparent during the Covid pandemic. Together these 21 century diseases lead to a reduction in healthy years of life and premature death. Poor population health and wellbeing, in turn, means lower productivity, greater costs and weaker economies.
The tragedy is that the knowledge required to break this vicious cycle exists, but is unappreciated or even ignored. The science of the early developmental origins of disease makes it clear that chronic non-communicable diseases have their origins in early life, in the womb and in early childhood. This is when trajectories of disease risk start, to be either attenuated or amplified across the life-course by environmental exposures and social factors sometimes outside the control of individuals, as well as by lifestyle choices and access to healthcare. So it is no surprise that the burdens of poor physical and mental health do not fall evenly across societies, but affect socially and economically disadvantaged groups more profoundly.
This is why The Venice Forum focused on the health of mothers and young children. Again, the data are startling. Diabetes in pregnancy, maternal over- or underweight, preterm birth and poor fetal growth now affect about half of all babies born around the world every year. Their poor start to life, a consequence of their mothers’ and grandmothers’ health experiences, and to an extent that of their fathers and grandfathers too, increases their likelihood of developing chronic non-communicable diseases as they grow older, and in turn to transmitting this health risk to their children. Poor maternal mental health also has profound effects on the young child, especially on the development which underpins behaviour, educational attainment and hence later contributions - and costs - to wider society. The result is that global health, and resilience to challenges like Covid-19, are being progressively and relentlessly eroded. Health and economics are inextricably entwined.
The pandemic has made a bad situation worse. Job and food insecurity, private and public debt, loss of traditional industries, reduced access to healthcare and education - have all led to a widening in inequalities, pushing over 70m people around the world into poverty. As always, women and children have suffered the most. Every member of The Venice Forum gave shocking examples of the effect of the pandemic on women and children. For example, in over a hundred low to middle-income countries access to contraception has been reduced, resulting in nearly 1.4m unintended pregnancies. Domestic violence to women has increased by 30-300% depending on the country. Over 100m children have missed a scheduled measles vaccination and an additional 7m have become malnourished or wasted.
The world has woken up to the devastating impacts of climate change and environmental despoliation on our chances of a sustainable future. But what appears not to have been widely appreciated is that the global decline in the health and wellbeing of women and young children is not only causing acute suffering now but will damage future population health and so too the very productivity and economic prosperity upon which responses to climate change will depend.
Why, The Venice Forum asked, has this powerful relationship between women’s and children’s health and sustainable, resilient economies been so difficult to incorporate into policy? One major issue is that the interventions needed require what may come to be viewed as new liberalism - policies that empower and create equity for women and young children. These interventions would need to address the root causes of vulnerability and inequity, and thus would represent a major change to the status quo. Whether in high, middle, or low-income countries, women undertake the majority of the unremunerated or poorly paid work that fuels societies – such as care for children and the elderly, domestic chores, and bearing children - but remain subservient to men in social standing, career opportunities, power, and wealth.
Add to this a related issue, namely that the needs of the young people who hold the keys to the future too often go unrecognised, in large part because their perspectives remain unrepresented at the ballot box. In this age of populism, classic liberalism has perhaps doubly failed, continuing to view women, children, and the vulnerable as recipients of either pity and charity, or gratitude, instead of recognising them as major contributors to societal and economic wellbeing. In many respects, women and young children remain non-persons, with little agency, whose needs and contributions are seen through a lens dating from an imperialistic, paternalistic and misogynistic past. The pre-eminent importance of women and young children to population health and future prosperity remains a global blind spot.
The interventions that will create better health for mothers and young children lie predominantly outside the healthcare sectors. The dominant view that economic growth, as measured by GDP, is the ultimate metric of success must give way to new thinking that emphasises policy framed in terms of human and planetary wellbeing. This includes economic models that attribute value to unremunerated contributions to society such as childbearing, and legislation that drives fair redistribution to men of unremunerated or poorly remunerated work currently largely carried out by women. It requires empowering women to fight their corner by providing them with education, financial and physical independence, and protecting their reproductive rights. A parallel requirement is to implement actions that enforce the UN Convention of the Rights of the Child, such as the right of infants and young children to receive optimal nurturing and care during the period that establishes their physical and mental health trajectories, and to have their perspectives recognised. This means, for example, incentivising men to share parenting responsibilities, ending the career and financial penalties that reward women for motherhood, lowering the voting age, and giving parents proxy votes for their children. These actions will be perceived by many to be as radical as was suffrage for women and people of colour. But most of us now look back on those days with horror.
A further reason is that, in tackling the challenge of non-communicable diseases, governments around the world have focussed their efforts primarily on interventions and treatments in adults, rather than on measures aimed at establishing healthy life-course trajectories. Thus the World Health Organisation and World Bank sponsored Global Action Plans for non-communicable diseases focused initially on four disease areas (cardiovascular disease, diabetes, chronic respiratory disease, and cancers) and four groups of risk factors (unhealthy diets, physical inactivity, tobacco use, and harmful use of alcohol), to which in 2018 they added mental health to the conditions and air pollution to the risks. Apart from a brief mention in the 2011 United Nations Political Declaration on the Prevention and Control of Non-Communicable Diseases, there has been little sign that global leaders have understood that breaking the causal cycle of transmission of physical and mental ill-health across generations through investment in the health of women and children will result in gains amplified over successive generations. This situation represents an extraordinary collective failure by policy-makers to understand the science of human development, but also an equal failure of scientists to get this message across. The Venice Forum wants to put this right.
It is also necessary to note that governments globally have failed for decades to stand up to the power of big business and corporate greed that has secured success for industries that cause ill health (tobacco, alcohol, fast food, environmental pollutants) or profit from disease (marketized healthcare). The pharmaceutical industries have made billions in profit, and paid billions in taxes, from the growing numbers of people dependent upon their treatments for chronic diseases. But there seems to be no good business case for disease prevention, especially when this depends on women’s and children’s health. Initial trials of Covid-19 vaccines excluded pregnant women and children, although there were no a priori biological reasons to justify this and it ran counter to World Health Organisation recommendations. This inevitably led to a lack of efficacy and safety data, inconsistent government advice, and a delay in making vaccines available in pregnancy and childhood. Classic economics simplistically subsidizes outputs that are considered “good” and taxes those considered “bad”. The world desperately needs an economic approach that is able to assign positive and negative values to outputs that benefit and detract from health, making the case for actively curbing the damaging effects of the latter.
The choice before the world, not just for governments but for all citizens who legitimise their policies and actions, is whether we want truly to build back better or are content to continue to paper over the cracks in social and economic structures that have been revealed so starkly by Covid-19? It took several decades for the world to wake up to the perils of climate change and the destruction of earth’s ecosystems. Let’s not add denial of waning population health as a result of inadequate attention to the wellbeing of mothers and young children to the charge sheet against humanity which future generations will rue.
(Article by Mark Hanson and Neena Modi for The Venice Forum).
1 The Venice Forum founders are Professors Neena Modi, Linda Giudice, Ariadne Malamitsi-Puchner, Flavia Bustreo, Gian Carlo Di Renzo and Mark Hanson, with Drs Chandni Maria Jacob and Despina Briana as Secretariat and Drs Michael Penkler, Sunil Bhopal and Ms Daniella Watson as rapporteurs.