**4. Discussion**

*Limitations:* The biggest limitation of this study relates to the necessity of using two differ‐ ent datasets—confirmed WHO data and UNICEF estimates of CMR, with the inevitable acknowledged inconsistencies [8, 20]. The biggest data inconsistency, however, concern South Africa, for example, UN‐estimated data that far exceeded WHO rates were avail‐ able. Self‐evidently, we are not in a position to state which figures are the most reliable; WHO data appear to hold a greater degree of internal consistency as, for example, UN rates compared to WHO data when available always show WHO rates as lower. The marked increases, based upon South Africa's 1990 WHO figure of 6431 pm, raise the question of the accuracy of earlier pre‐1994 apartheid regime figures. It *may* be that the former regime would have been less likely to include rural Black deaths. This in part *might* account for some of their rises though there have been increases in treatment‐resistant TB and HIV/ AIDS deaths in the country, which may have contributed to real rises in CMR [42–44]. Conversely, the increases could be due to more accurate reporting systems yet only country‐ specific research could confirm this. Another limitation is that 14 of the SSA countries faced civil conflict during the period, which is very likely to have affected those countries ability to meet the UN millennium goal, although five of these countries, for example, Liberia and Ethiopia, did meet the target.

These limitations mean that these results cannot be definitive. Rather, they are indicative of changes found in other studies of non‐Western societies such as Islamic, Latin American and former Warsaw Pact countries related to suicide and child‐abuse‐related deaths, where data accuracy has been found to be problematic because of cultural and political taboos [15–17]. Nonetheless, despite these limitations, this first‐ever comparative study of societies' response to children in three world regions provides significant indicators of those meriting a rela‐ tive regional *reproach* or *commendation*. More importantly, these results provide a baseline for future comparative studies and how well or otherwise these societies are meeting the needs of their children.

## **4.1. The West**

Most Western governments can be congratulated on the impressive reduction in mortality rates, but the *USA, New Zealand and Canada* are classed as a *reproach* for having CMR 1 SD above the regional mean. Are these countries relatively neglecting the needs of their children? As far as the UK is concerned, it had the fourth highest CMR of the 21 countries alongside the third highest income inequality figure; it has been found that British children, in regard to poverty and health expenditure, are significantly disadvantaged compared to other Western societies [13, 45]. The fact that the six highest CMR occurred in English‐speaking countries suggests that, despite major reductions, there are cultural factors influencing CMR. Are English‐speaking societies less child‐focused than other Western nations?

Relative poverty and higher CMR are significantly correlated, which is seen in the fact that the five Western countries with the highest CMR occupied the six widest income inequali‐ ties positions. Conversely, countries with the narrowest income inequalities have the lowest CMR, that is, Sweden, Finland, Japan and Norway, meriting their *commendation*, as well as *Greece* and *Portugal,* who had the biggest CMR reduction in the region.

#### **4.2. Asia**

**4. Discussion**

78 International Development

Ethiopia, did meet the target.

of their children.

**4.1. The West**

*Limitations:* The biggest limitation of this study relates to the necessity of using two differ‐ ent datasets—confirmed WHO data and UNICEF estimates of CMR, with the inevitable acknowledged inconsistencies [8, 20]. The biggest data inconsistency, however, concern South Africa, for example, UN‐estimated data that far exceeded WHO rates were avail‐ able. Self‐evidently, we are not in a position to state which figures are the most reliable; WHO data appear to hold a greater degree of internal consistency as, for example, UN rates compared to WHO data when available always show WHO rates as lower. The marked increases, based upon South Africa's 1990 WHO figure of 6431 pm, raise the question of the accuracy of earlier pre‐1994 apartheid regime figures. It *may* be that the former regime would have been less likely to include rural Black deaths. This in part *might* account for some of their rises though there have been increases in treatment‐resistant TB and HIV/ AIDS deaths in the country, which may have contributed to real rises in CMR [42–44]. Conversely, the increases could be due to more accurate reporting systems yet only country‐ specific research could confirm this. Another limitation is that 14 of the SSA countries faced civil conflict during the period, which is very likely to have affected those countries ability to meet the UN millennium goal, although five of these countries, for example, Liberia and

These limitations mean that these results cannot be definitive. Rather, they are indicative of changes found in other studies of non‐Western societies such as Islamic, Latin American and former Warsaw Pact countries related to suicide and child‐abuse‐related deaths, where data accuracy has been found to be problematic because of cultural and political taboos [15–17]. Nonetheless, despite these limitations, this first‐ever comparative study of societies' response to children in three world regions provides significant indicators of those meriting a rela‐ tive regional *reproach* or *commendation*. More importantly, these results provide a baseline for future comparative studies and how well or otherwise these societies are meeting the needs

Most Western governments can be congratulated on the impressive reduction in mortality rates, but the *USA, New Zealand and Canada* are classed as a *reproach* for having CMR 1 SD above the regional mean. Are these countries relatively neglecting the needs of their children? As far as the UK is concerned, it had the fourth highest CMR of the 21 countries alongside the third highest income inequality figure; it has been found that British children, in regard to poverty and health expenditure, are significantly disadvantaged compared to other Western societies [13, 45]. The fact that the six highest CMR occurred in English‐speaking countries suggests that, despite major reductions, there are cultural factors influencing CMR. Are

Relative poverty and higher CMR are significantly correlated, which is seen in the fact that the five Western countries with the highest CMR occupied the six widest income inequali‐ ties positions. Conversely, countries with the narrowest income inequalities have the lowest

English‐speaking societies less child‐focused than other Western nations?

There is a very strong correlation between CMR and relative poverty in Asian countries. Whilst *Hong Kong and Singapore* have lower CMR than the West's average, seven non‐indus‐ trialised Asian countries had impressive reductions (more than 40%) in their CMR. *Singapore and Thailand* with their relatively high GNI figures and CMR 1 SD below the mean merit a *commendation*. However, *Pakistan, India and Myanmar* are a relative *reproach*.

#### **4.3. Sub‐Saharan Africa**

Even acknowledging the incredible poverty of Africa compared with much of Asia and the West**,** the levels of CMR are overwhelming. Averaging 3.1% of all under‐fives dying, surely this is a continent of hidden and silent sorrows. However, it is noted that some SSA countries, such as Nigeria, Angola and South Africa are among the top 20 oil‐producing and mineral‐supplying nations [28] yet all failed the UN challenge. Against expectations, some relatively richer countries, for example, Nigeria have higher CMR, whilst lower income countries such as Madagascar have lower figures. Further country‐specific research is required to explain these apparent anomalies.

#### **4.4. Governments**

What also has to be recognised is that globally *the rich are getting richer*. Inequality continues to widen in such countries as the UK [46] and according to Credit Suisse, 0.7% of the world's population has increased its wealth holding to 44% of global wealth and 8.6% of the world's population now own 85% of the world's wealth [47]. The authors of this Credit Suisse Report argue that rapid increases in income inequality often lead to economic recession and in view of the current global economic situation, this gives further impetus to consider not only the current situation of children, but if these inequalities continue what will the outcome be? Therefore, when we see evidence of the social consequences of not achieving the UN goal of reducing child mortality, with its statistical link to poverty in Western, Asian and African societies, we should speak out. The UN millennium aspiration is essentially a campaign for social justice and we need to highlight the very corrosive effect of poverty and its impact upon children in *every continent*, for to be respectably silent is surely not an option. Hence, we have an obligation to hold our individual societies and governments to account, especially to those societies who merited a *reproach*.

When exploring the percentage of GDP on military expenditure, it was significant that the higher military expenditure in the West was statistically linked with worse income inequality, but not in the other regions. However, when considering the comparison of health and mili‐ tary expenditure ratios in Asia and Africa, we are ill‐equipped to comment, in part because of unavailable data and the various countries perceived security threats. However, we recall the valedictory address of President Eisenhower, America's top general and commander‐in‐chief of the Allied war in Europe, who warned of the inherent socio‐economic‐political dangers of the 'military industrial complex'.

*We have been compelled to create a permanent armaments industry of vast proportions……………….. We annually spend on military security more than the net income of all United States corporations.*

*This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence -- economic, political, even spiritual -- is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. [But]*

*In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist. [48] [Our preposition].*

When discussing CMR, in one sense, using rates distances us, but rates are statistics, num‐ bers are real children. One practical feature must be the accumulative societal impact of high child mortality as bereavement itself is damaging to family health [49, 50]. Losing a child must be one of the worst and bitter tragedies for any parent in whatever world region and should be a focus of future research. So what do these rates mean in terms of relative excess' deaths of children? The USA and UK, who claim to be the mature and greatest democracies, have somewhat distorted political priorities, not only warned of by President Eisenhower, but former Chief of Staff General Colin Powell, who complained the US military was out of tilt and distorting the US economy [51]. Yet the US and the UK have the higher military to health expenditure ratios, reflecting their priorities. Does this influence the conjugation that if the UK and USA had the same current CMR of Portugal, who had been the highest Western country in 1989–1991, then there would be 850 fewer dead children in Britain and 13,591 fewer American grieving parents, more than four times the worst ever terrorist atroc‐ ity. Indeed, both countries' CMR substantially exceeded that of Hong Kong, Singapore and South Korea. It might be argued that for every bullet, plane and tank manufactured, poten‐ tially it is taking the sustenance from children in need, not only in the West but also in the other two regions.

One excuse for SSA is they only have imperfect or new democracies, which we do not accept as apartheid ended 26 years ago and forthcoming research over a similar period of the former Warsaw Pact countries, shows that eight of them now have lower CMR than the USA, so with such considerable improvement, we should have greater expectations for post‐apartheid Africa.

In all three regions, there seem to be questionable priorities: countries with narrow ratios, nar‐ rower than the average, such as Greece, Australia, UK and the USA, all less than 1:5.5, should be challenged as to the rationale in relation to their CMR. In Asia, except Japan, they have a far 'worse' health to military ratio, averaging 1:2.3. Again, surely this should raise questions as to their priorities—especially Myanmar and Pakistan, who spend more on military than on health and who have the highest CMR in Asia. In view of India's economic success, their ratio of 1:1.7 in part may be a reaction to their neighbour's military expenditure, but again should be challenged.

Finally, on the 'government' side of Penn's dictum, Sub‐Sahara‐Africa military: health ratios vary considerably, averaging 1:4.4. However, for 12 of the 27 SSA countries for whom we have data are below the 'average' and in view of CMR toll is of itself a reproach. For in the last analysis, every gun, tank and plane manufactured is competing for feeding and providing adequate healthcare for their children. This is reported with great sadness, but we must never be afraid to report what we find even if it can inadvertently be re‐framed as racist, as politi‐ cians over the centuries have used patriotism as the last refuge for the political scoundrel.

#### **4.5. Religion**

*We have been compelled to create a permanent armaments industry of vast proportions……………….. We annually spend on military security more than the net income of all United States corporations.*

*This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence -- economic, political, even spiritual -- is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this* 

*In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced* 

When discussing CMR, in one sense, using rates distances us, but rates are statistics, num‐ bers are real children. One practical feature must be the accumulative societal impact of high child mortality as bereavement itself is damaging to family health [49, 50]. Losing a child must be one of the worst and bitter tragedies for any parent in whatever world region and should be a focus of future research. So what do these rates mean in terms of relative excess' deaths of children? The USA and UK, who claim to be the mature and greatest democracies, have somewhat distorted political priorities, not only warned of by President Eisenhower, but former Chief of Staff General Colin Powell, who complained the US military was out of tilt and distorting the US economy [51]. Yet the US and the UK have the higher military to health expenditure ratios, reflecting their priorities. Does this influence the conjugation that if the UK and USA had the same current CMR of Portugal, who had been the highest Western country in 1989–1991, then there would be 850 fewer dead children in Britain and 13,591 fewer American grieving parents, more than four times the worst ever terrorist atroc‐ ity. Indeed, both countries' CMR substantially exceeded that of Hong Kong, Singapore and South Korea. It might be argued that for every bullet, plane and tank manufactured, poten‐ tially it is taking the sustenance from children in need, not only in the West but also in the

One excuse for SSA is they only have imperfect or new democracies, which we do not accept as apartheid ended 26 years ago and forthcoming research over a similar period of the former Warsaw Pact countries, shows that eight of them now have lower CMR than the USA, so with such considerable improvement, we should have greater expectations for

In all three regions, there seem to be questionable priorities: countries with narrow ratios, nar‐ rower than the average, such as Greece, Australia, UK and the USA, all less than 1:5.5, should be challenged as to the rationale in relation to their CMR. In Asia, except Japan, they have a far 'worse' health to military ratio, averaging 1:2.3. Again, surely this should raise questions as to their priorities—especially Myanmar and Pakistan, who spend more on military than on health and who have the highest CMR in Asia. In view of India's economic success, their ratio of 1:1.7 in part may be a reaction to their neighbour's military expenditure, but again should be challenged. Finally, on the 'government' side of Penn's dictum, Sub‐Sahara‐Africa military: health ratios vary considerably, averaging 1:4.4. However, for 12 of the 27 SSA countries for whom we have data are below the 'average' and in view of CMR toll is of itself a reproach. For in the last analysis, every gun, tank and plane manufactured is competing for feeding and providing adequate healthcare for their children. This is reported with great sadness, but we must never

*development. [But]*

80 International Development

other two regions.

post‐apartheid Africa.

*power exists and will persist. [48] [Our preposition].*

William Penn (1693) condemned both government and religion [38], however. Christianity and Islam, the main religions in the West, Asia and Africa, hold strong socially positive mes‐ sages about the care of children. Both condemn child neglect and abuse in the strongest terms. For example, Jesus of Nazareth, also revered in Islam, denounces those who actively or pas‐ sively neglect and abuse children:

*but whosoever shall hurteth one of my little ones, it were better for him that a millstone were hanged about his neck and that he were cast into the depth of the sea (Matthew 18.v 6).*

From the Qur' an, there are clear obligations concerning how to treat and give priority to chil‐ dren, for example; '*He who treats the orphan with harshness and does not encourage feeding the poor so woe be to such praying ones, who are unmindful of their prayers!'* (Chapter 107 Al‐Maum: 2‐5). Those who ignore the poverty issue related to children are particularly condemned:

*Nay but you do not honour the orphan Nor do you urge one another to feed the poor and love wealth with exceeding love (Chapter 89 Al-Fajr: 17, 18).*

Therefore, these two faiths come together to reinforce Penn's (1693) message that '*it is a reproach to religion and government to suffer so much poverty and excess'.*
