Abstract
Since its inception 3 decades ago the Asia-Pacific Academic Consortium for Public Health (APACPH) has emphasized improving the health of disadvantaged and minority groups. In 1990, APACPH held a conference in Kathmandu with the theme, “The Girl Child in Asia: A Neglected Majority.” Over the past 3 decades, the mortality rates for all children, particularly girls, have improved in our region.
Professor Walter Patrick was present at the WHO Health for All Conference in Alma Ata in 1978, and in all the Asia-Pacific Academic Consortium for Public Health (APACPH) conferences that he subsequently attended he emphasized the provision of primary care and public health services for those who were disadvantaged. One of the important disadvantaged groups in our region was female children. In December 1990, Prof Patrick was instrumental in promoting an APACPH conference with the theme, “The Girl Child in Asia: A Neglected Majority,” which was held in Kathmandu.
In the keynote address to the conference, the Regional Director (SEARO) of WHO, Dr D B Bisht stated, “Deliverance from death and suffering is one of the earliest prayers to the Divine and is embodied in the ancient Sanskrit text: ‘Oh Lord! Lead us from falsehood to truth, from darkness to light, and from death to immortality.’ Whereas freedom from death may be the ultimate though elusive goal of life on earth, freedom from suffering and premature mortality can certainly be achieved.”
Dr Bisht highlighted concerns with poor nutrition and fewer education opportunities for girls: Girls below the age of five are far more malnourished than boys and this is also true of the nutritional status of women as compared to men. Food is often denied to girls and women, unfortunately, by mothers themselves who prefer to give more food to their sons than to their daughters.
1
and There are wide disparities in the education of males and females, the “education gender gap.” The causes lie in the complex mix of cultural and economic factors, viz. education has direct costs, e.g., clothes and school supplies, and indirect costs through the loss of domestic work and home based labor such as carpet making. There are also cultural costs which influence parents into thinking that girls cannot be sent to school alone, particularly to coeducational schools or schools with only male teachers, and which lead to girls dropping out on reaching puberty and marrying early.”1, p 214
The large discrepancy in education between genders in Bangladesh was described in the article by Islam. 2
At the conference, the “Declaration of Kathmandu: a Commitment to Girl Child Survival, Protection and Development in Asia” was adopted.3, p 209 The preamble to the declaration stated, The Challenge presented by the deaths of 40 000 children each day from malnutrition and disease, the majority of whom are girls, and by the suffering endured by millions of children from poverty, hunger, neglect, exploitation, abuse, war and violence; Realizing the opportunity provided through international academic collaboration in public health to enhance the survival, growth and protection of female children.
The resolution then went on to propose that the members of APACPH work together to achieve marked improvements in the health of girls: protect and promote and not violate or neglect the rights of female children, particularly in terms of child labour and sexual abuse, and that girl children are able to benefit equitably from health, nutrition, education and other basic social services.
Now, 25 years after the Kathmandu resolution, it is appropriate to review progress toward the achievement of these goals in the Asia-Pacific region. Some years after the declaration the need for special emphasis on girls and mothers in public health was recognized in the Millennium Development Goals. There was an emphasis on the need to address disadvantaged groups, which included girls. Specifically, gender issues in children were mentioned in goal 2, “Achieve universal primary education,” the target, “Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling,” and Goal 3, “Promote gender equality and empower women,” including the target to “Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.”
Girls grow up to be mothers and their health, nutrition, and growth is important in preparing them to be mothers of the next generation. Poor nutrition in early life leads to stunting. 4 Reduced attained height is probably the best index of overall growth and reflects the size of a pelvis. 5 A study of 14 000 deliveries in Hong Kong showed a continuous inverse relationship between maternal height and caesarean section and neonatal outcome. 5 These results were similar to an earlier study from Sweden, which showed that maternal height was more important than ethnicity in determining obstetric outcomes. 6 These studies emphasize the importance of early nutrition for girls to reduce stunting rates.
The equation is simple but can be devastating for mother and infant: poor nutrition results in stunted growth, which includes reduced height and a small pelvic size, which is a risk factor for difficult births, including obstructed labor, with increased risk to mother and infant. Prevention of stunting through adequate nutrition is more likely to prevent obstetric complications than screening prior to delivery. Education of women (girls) is one of the most important interventions in improving nutrition. Educating girls for 6 years or more drastically and consistently improves their prenatal care, postnatal care, and childbirth survival rates. Educating mothers also greatly cuts the death rate of children younger than 5 years. 7
The poor nutrition of girls is also evident when they have their own children. They may be undernourished themselves, and their infants may also suffer from undernutrition. Recent research on the development of health and disease hypothesis and the emerging science of epigenetics show the importance of poor nutrition of the mother on the intergenerational transfer of chronic disease.8,9
In many countries in the Asia-Pacific region, there has been a discrimination against girls before they are born. Without intervention the male to female gender ratios at birth is usually 1.06. 10 But in some cultures, boys are more highly desired than girls, the former being regarded as an economic asset and the latter as cost burden to the family. In recent decades, the male to female ratio has risen as high as 1.40 in the Asian region. 11 In China, the number of missing women in the 20th century has been estimated at 35 million. 12 Much has been written about the missing girls and women of our region, and the social implication of this gender deficit is an important public issue. 12 The most recent data suggest that there is still a major problem with gender ratios at birth in some countries in our region 13 (see Table 1).
Gender Ratio, Male/Female (M/F) at Birth. a
Source: Guilmoto. 13
Prof Patrick was concerned about equity, including gender and health outcomes, across socioeconomic groups when he wrote, In the less developed countries (LDCs), including those in the Asia-Pacific region where some have dramatically reduced their overall infant mortality rate (IMR), the pattern is similar to that in the U.S. The poorer segments of those societies, often represented by ethnic minorities, have two to four times the IMR of the socially advantaged groups. In many cases, these affected populations are not isolated pockets of the poor and underprivileged but are made up of large segments of those societies, i.e., the 40% who live on 10% or less of the total national income. The chances of survival for babies in those circumstances, even survival to the first year of life, are lost from sight in national averages of economic development.14, p 5
The number of children not receiving education has decreased over the past decades. In 1999, there were 106 million children not in school, and this fell to 57million in 2012. In the Asian region, the percentage of children not in school fell from 12.5% to 7.5%. 15 There are still slightly more girls than boys not receiving schooling, but the gap has narrowed.
A good example of the way public health can improve the health of girls and women is the improvement shown in nutrition and health in Korea. In the past 50 years, Korea has improved its health and nutrition indicators more rapidly than any other large country. Infant mortality declined from 350/1000 live births at the beginning of the 20th century to 109 in 1950 and is currently 4.01. The completed height of boys and girls in Korea has increased at the rate of 1.1 cm/decade for boys and girls in Korea, meaning that few girls are now stunted, and obstetric outcomes have improved. In 1990, the under-5 mortality rate in the Republic of Korea was 7, and this has now decreased to 4 for both genders (see Table 2). Now, Korea has the same difficulties with overnutrition as many other Asian countries, resulting in an increase in obesity.
Gender-Specific Under-5 Mortality Rate (U5MR). a
Source: . 15
Since the 1990 APACPH declaration, the health and nutrition of girls in the Asia-Pacific region have improved considerably. The data in Table 2 show that apart from the Indian subcontinent, the poorer nutrition of girls was not reflected in child mortality rates. However, the rates from the 1990s may reflect underreporting of girls’ deaths, as shown in China. 16
Conclusion
In the quarter of a century since the APACPH meeting on the girl child, the health and nutrition of girls in our region has improved. This has been promoted by the Millennium Development Goals and no doubt assisted by the educational programs of APACPH. Prof Patrick’s dream of equality in terms of outcomes between boys and girls has been achieved in most of the countries in the Asia-Pacific region. However, there remain continuing challenges to be addressed, including gender ratio at birth, gender-related violence, early marriages, and the right to fertility control. It remains a challenge for APACPH to address these concerns enunciated by Prof Patrick.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.