Authors: Adam Fifield
Then the first lady surprised everyone. She mentioned that one of Grant’s “greatest hopes” was that the UN treaty on children’s rights “would serve as a standard of principle that would guide us into the next century.” She paused and then
continued: “Therefore … I am pleased to announce that the United States will sign the United Nations Convention on the Rights of the Child.”
Sudden applause rippled through the cathedral. Smiles tugged on solemn faces as astonishment radiated through the crowd. Some people swiveled in their seats, whispering to those sitting next to them, perhaps saying,
Can you believe it? Can you believe it?
Grant’s last request had been answered.
Taking the full measure of Jim Grant’s legacy is like trying to wrap your arms around a redwood tree—you can grip parts of it, but you’ll never grasp the whole thing. UNICEF has estimated that his child survival revolution saved 25 million children’s lives during the fifteen years he ran the organization. But the policies and programs he spawned—at UNICEF and in governments throughout the world—continued to reap lifesaving rewards long after his death, helping to steadily drive down child mortality.
Between 1980 and 2013, the global mortality rate for children under age five plummeted from 117 deaths per 1,000 live births to 46 deaths, according to estimates from the UN’s Interagency Group for Child Mortality Estimation. During that time, the number of child deaths fell from 13.9 million per year to 6.3 million. And this occurred despite a huge increase in population. The group also calculated that since 1990, almost 100 million children’s lives have been saved by the worldwide effort to
combat child deaths (though it overlaps by five years with the 25 million figure cited above, this estimate cannot be compared or added to the earlier figure; the numbers are likely based on different data and methods of calculation). These successes reflect the work of many people and span more than eighteen years after Grant’s ashes were scattered on a California mountain, but his influence is indelibly stitched into them. Much of the overall recent progress in international development and global health also bears his fingerprints.
But that progress is not as robust as it could be. After Grant’s death, the historic, high-octane momentum he created began to fumble and falter. Immunization rates stagnated, and the decline in child mortality slowed. There were many reasons for this: the merciless and growing toll of the AIDS epidemic, donor fatigue, a slackening in the investment of national governments, and cutbacks in services spurred by structural adjustment programs. But many feel that the overwhelming factor was the stark lack of a bold, unifying voice.
UNICEF’s public profile has also diminished considerably since Grant—its annual flagship report,
The State of the World’s Children
, garners a fraction of the attention that it received during his tenure.
“UNICEF, very specifically after Jim, took a nosedive in its leadership,” says Robert Black, chairman of international health at the Johns Hopkins Bloomberg School of Public Health. No subsequent executive director, he adds, has brought the energy or clarity of vision provided by Grant.
Black was one of the authors of an influential 2003 series in the British medical journal the
Lancet
, which found that attention to and investment in child survival programs had slumped during the late 1990s and which called for a renewed commitment to carry on the work Jim Grant had started. The following year, the
Lancet
’s editor, Richard Horton, wrote a blistering editorial charging that UNICEF had “lost its way” under Grant’s immediate successor, Carol Bellamy. By focusing too much on the matter of “child rights,” Bellamy had essentially dropped the ball on child survival, according to Horton. “This rights-based approach to the future of children fits well with the zeitgeist of international development policy,” he wrote. “But a preoccupation with rights ignores the fact that children will have no opportunity for development at all unless they survive. The language of rights means little to a child stillborn, an infant dying in pain from pneumonia, or a child dessicated by famine. The most fundamental right of all is the right to survive.” Horton asserted that “child survival must sit at the core of UNICEF’s advocacy and country work. Currently, and shamefully, it does not.”
Black claims that immunization programs became a lower priority during Bellamy’s tenure, which he calls “criminal.” “It was so irresponsible,” he says. “With Bellamy, the medical approach was out and it was not really her priority. She could have just as well focused on human rights and continued some of the things, but this was a political regime that came in and rejected the previous one.”
Bellamy sees this a little differently. The former head of the US Peace Corps, who had served as the president of the New York City Council in the late 1970s and early 1980s and had also worked as an investment banker, was known for her toughness and short temper. She was nominated to succeed Grant by President Bill Clinton. Clinton had initially supported Grant’s choice, Bill Foege. But, after Grant’s death, the president was forced to drop Foege in light of UN secretary general Boutros Boutros-Ghali’s insistence that the next head of UNICEF be a woman (Grant was obviously no longer around to say anything about it).
To Bellamy’s credit, she did give priority to important issues that some feel Grant had neglected, including child protection and HIV/AIDS. She flatly denies that she rejected Grant’s regime and speaks of her predecessor in the most glowing terms. “It’s much harder following a God,” she says, “than following somebody who hasn’t been that highly regarded.”
Bellamy insists that immunization and child health programs remained significant priorities during her administration—she simply wanted to tackle other problems as well. “I suppose it is correct that there is less attention, but there was still attention to child survival,” she says. “The attention … I believe, correctly broadened to include other critical issues that were confronting children.” Some former UNICEF staff members feel that the
Lancet
editorial was unfair and praise Bellamy for tightening UNICEF’s management systems, strengthening its support for education, promoting the advancement of girls, enhancing its emergency response
programs, and, in 1997, for successfully resisting an ill-advised and potentially disastrous plan to merge UNICEF with other UN development operations.
Regardless of Bellamy’s accomplishments—and many were considerable—it is indisputable that UNICEF lost its place at the vanguard of child survival during her tenure. She didn’t abandon the issue entirely, but she did relinquish the organization’s role as the leader of the child survival revolution. To this day, no one has reclaimed it.
Some blame Grant himself for part of this. One of the biggest criticisms leveled against him—in addition to his avoidance of administrative and budgetary issues he considered unpleasant—was that he left UNICEF in a compromised position. He took the agency to unimagined heights, but he also ran it ragged. His blind spot for ethically deficient employees effectively allowed some unsavory staff members to injure his agency and his mission. He also exalted the all-or-nothing pursuit of goals over everything else.
His loyalists point out that none of this was ever about trying to enrich himself or advance his own position—it was always about the mission. Even so, the lapses contributed to credibility problems and opened the door for his successor to make major changes. He did not plan for a UNICEF that outlasted him—even though he knew it would—and the organization suffered as a result.
Several former UNICEF staffers also believe that some of the unparalleled feats he set in motion were hasty and unsustainable—too focused on the quick fix, the dramatic
marketing message, the “doable” success story. Many wonder if his legacy would be even stronger had he been more careful.
A year after Grant’s death, a committee of outside experts convened by UNICEF issued a detailed report on the strengths and shortcomings of the universal child immunization campaign. Chaired by Dr. F. Marc LaForce, the committee lauded UNICEF and its partners for putting children’s health in the “public and political eye” and for undertaking an effort that “prevented a remarkable amount of disease and death in children.” But LaForce and his team also concluded that the historic global endeavor had excessively focused on short-term goals to the detriment of long-term sustainability. According to their report, funding for immunization programs in some countries had actually started declining in the early 1990s after the excitement of the 1990 deadline had worn off. The mad dash to meet immunization targets by 1990, they claimed, may have siphoned resources from other important programs, led to “shortsighted” decisions, encouraged the manipulation of data for political benefit, and made some countries too dependent on external sources of funding that would eventually dry up. After interviewing 150 people at UNICEF, WHO, government ministries, and NGOs, the committee found that “reports of problems with campaigns generally outweighed reports of advantages.”
The committee offered valuable recommendations for improving UNICEF’s immunization work and raised valid questions. And yet—despite the swarm of concerns about sustainability and waning commitment and overambitious goals and shortsighted decisions—the UCI gains
have
largely been
sustained. According to WHO estimates, global coverage levels achieved in 1990 did not go up much over the following decade—but they didn’t go down much either. With some declines here and there, they basically held firm, saving as many as three million children’s lives year after year. Some countries did experience major drops throughout the 1990s (particularly in sub-Saharan Africa), but the rates did not generally fall to 1980 levels. Had Grant been more cautious, had he taken the time to focus more on long-term planning and sustainability, would he have accomplished as much? His approach was a calculated gamble that could have failed. But it worked.
Sustainability is important, but it can also be a synonym for complacency, says Kul Gautam. Being bold and pushing hard for huge leaps in immunization coverage will make much more of an impact than carefully maintaining minor increases, he says. “If you go from 20 [percent] to 70, and then somehow go down to 60, that is not a disaster,” he explains. “It is still better than the so-called sustainable way that many people were pushing, [people] who were too easily satisfied with modest gains.”
Starting in 2000, after the Gates Foundation funded the creation of the Global Alliance on Vaccines and Immunization (GAVI), the stagnant rates started to go up again.
Grant’s greatest weapon—the reason he was able to essentially get four-fifths of the world’s children immunized and spark a global movement involving millions of people—was the children themselves. As he often said, “Who can say no to children?”
But a few people did say no. A total of 195 nations have ratified the Convention on the Rights of the Child, but the
United States is not one of them. While President Bill Clinton’s administration did sign the treaty—as Hillary Clinton had promised—the US Senate needs to ratify it for it to take effect. As of this book’s first printing, it has not done so. The only other holdout is the newly created nation of South Sudan (the lawless state of Somalia ratified the treaty in January 2015). Some of the reasons cited for US recalcitrance over the years: the treaty prohibits the death penalty for minors (this is now moot; the US Supreme Court abolished juvenile executions in 2005), it does not expressly oppose abortion, and it limits parents’ ability to discipline their kids. All are ludicrous, born mostly of conservative fear mongering.
What of Grant’s mid-decade goals—the grand aspirations that stubbornly gripped his thoughts even in his final moments? As of July 1996, a year and a half after his death, a report by UN secretary general Boutros Boutros-Ghali found that most countries were on track to achieve most of the mid-decade targets. Ghali’s study said the World Summit for Children goal process had unleashed “an extraordinary mobilizing power, generating a renewed level of activity on behalf of children around the world and creating new partnerships between Governments, NGOs, donors, the media, civil society and international organizations in pursuit of a common purpose.” The report cited “striking progress” on immunization coverage, diarrheal diseases, polio, guinea worm, iodine deficiency disorders, access to safe drinking water, and breast-feeding promotion. The secretary general also noted that fifteen countries had incorporated the principles of the Convention on the Rights of
the Child into their constitutions and that more than thirty-five had passed new laws to bring them in line with the convention. A few areas, including primary education and malnutrition, showed little progress. Sub-Saharan Africa and South Asia were also trailing behind other regions (as Gautam and others had warned they would, if the goals were not customized for each country).
Five years later, the new secretary general, Kofi Annan, released an update on the year 2000 summit goals—and this one was not as rosy. Some goals, he said, had sparked major gains since 1990: 1.5 billion people using iodized salt, sixty countries achieving a one-third reduction in child mortality, 175 countries now polio-free, one million fewer diarrhea deaths, a 40 percent decrease in the incidence of measles, a 50 percent reduction in neonatal tetanus deaths. Even with so many triumphs, Annan announced, most of the summit targets had not been reached. He attempted to explain why: “We have fallen short largely because the needed investments for children were not made.” Both donor and developing countries had simply not set aside enough money. He cited other impediments: the widening gulf between rich and poor, the punishing burden of debt, the increase of conflict, the scourge of AIDS.
Another possible reason Annan did not mention: the absence of Jim Grant (and his stalwarts who had departed UNICEF, like Nyi Nyi).
The pest, the nudge, the unstoppable irritant was simply no longer there to whisper in countries’ ears:
You’ve got to do more! And you’ve got to do it now!