Conti, G

Hanson, M

Modi, N

English

Twenty-first century science underpinned the rapid global response to COVID-19, identifying the causal pathogen, sequencing the SARS-CoV-2 genome, developing vaccines and initiating clinical trials, within 9 months of first appearance. Although in tackling the immediate consequences of the pandemic countries responded to science in different ways, every nation now grapples with the economic consequences and the question of where to focus investment. Here, we argue that insights from 21st century science can also lead the way to economic recovery. These indicate that there should be a prime focus on healthy populations resilient to unexpected challenges and that this is to a large extent dependent on maternal, neonatal and child health (MNCH). Recovery from COVID-19 offers a unique opportunity to target investment on MNCH

Modi, Neena

Conti, Gabriella

Hanson, Mark

UCL Discovery

Confidential: For Review OnlyPost-COVID economic recovery: women and children first…or last? Journal: Archives of Disease in ChildhoodManuscript ID archdischild-2020-320898.R2Article Type: ViewpointDate Submitted by the Author: n/aComplete List of Authors: Modi, Neena; Imperial College London, Section of Neonatal Medicine, School of Public HealthConti, Gabriella; University College London, Department of Economics and Social Research Institute, Hanson, Marc; University of Southampton School of MedicineKeywords: Neonatology, Epidemiology https://mc.manuscriptcentral.com/adcArchives of Disease in ChildhoodConfidential: For Review OnlyI, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence.The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set out in our licence referred to above. Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate material already published. I confirm all authors consent to publication of this Work and authorise the granting of this licence. Page 1 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Confidential: For Review OnlyTitle pageTitle: Post-COVID economic recovery: women and children first…or last? Authors: Neena Modi1, Gabriella Conti2, Mark Hanson3  1 Neena Modi MD FMedSci, Professor of Neonatal Medicine, Faculty of Medicine, School of  Public Health, Imperial College London, London, UK  2 Gabriella Conti PhD, Associate Professor in Economics, Department of Economics and Social Research Institute, University College London, London, UK  3 Mark Hanson DPhil, British Heart Foundation Professor, Institute of Developmental Sciences and NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton, UK 9 Word count of manuscript text: 1197 Corresponding author's complete contact information:  Professor Neena Modi, Section of Neonatal Medicine, Faculty of Medicine, School of Public Health, Imperial College London, Chelsea and Westminster Hospital campus, 369 Fulham Road, London, SW109NH, UK Email: n.modi@imperial.ac.uk Page 2 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Confidential: For Review OnlyPost-COVID economic recovery: women and children first…or last? 21st century science underpinned the rapid global response to COVID-19, identifying the causal pathogen, sequencing the SARS-CoV-2 genome, developing vaccines and initiating clinical trials, within nine months of first appearance. Although in tackling the immediate consequences of the pandemic, countries responded to the science in different ways, every nation now grapples with the economic consequences and the question of where to focus investment. Here, we argue that insights from 21st century science can also lead the way to economic recovery. These indicate that a prime focus should healthy populations, resilient to unexpected challenges, and that this is to large extent dependent on maternal, neonatal and child health (MNCH). Recovery from COVID-19 offers unique opportunity to target investment on MNCH.  Post-COVID economic recovery will have to take place against the continuing backdrop of the growing population prevalence of chronic non-communicable diseases (NCD) that are progressively crippling health systems, societies, and economies. Thus, in 2019, the US witnessed a reversal of the rise in life expectancy and healthy longevity that characterised previous decades. Pre-COVID policies were unable to tackle these challenges hence restoring the status quo appears to be a doomed strategy. However, science shows clearly that MNCH is of pivotal importance to preventing and reducing the population prevalence of physical and mental NCD (1). For example, babies born preterm, growth restricted or to an under-nourished, overweight or diabetic mother represent a large and growing proportion of all births and are at substantially increased odds of developing hypertension, diabetes, renal impairment, heart disease and other chronic NCD in adult life (2). In high-income countries, around two-thirds of adults are now overweight or obese. Preterm births are rising, with an estimated global rate of 10.6% in 2014 (3).  The prevalence of malnutrition among pregnant women in Africa is estimated at 23.5% (95%CI: 17.72–29.32) (4). Intergenerational transmission is worsening these problems, as a woman born preterm is more likely to deliver preterm, and the daughter of an obese mother to become obese herself. Approaches focused upon MNCH would benefit human potential through multiple determinant pathways that include education, empowerment, mental wellbeing and personal resilience in addition to health. Uniquely, investment today will amplify returns across successive generations. The dominant view of economic recovery is that it must reverse the dramatic fall in Gross Domestic Product (GDP) caused by the response to the pandemic. However, GDP is a flawed biomarker of a country's wellbeing (5). GDP represents the monetary value of goods and Page 3 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Confidential: For Review Onlyservices produced over a period but as it does not take their impact on population health into account though this is crucial to economic stability. Thus, GDP includes the outputs of the tobacco and fast food industries but does not subtract the costs of their contributions to cancer and obesity. GDP does not incorporate the contributions to the economy of child bearing and child rearing though these are powerful determinants of physical and mental wellbeing, and adult productivity. Likewise, the manufacture of infant formula contributes to GDP, but breast-feeding, which has major, quantifiable benefits upon the health of mothers and babies, does not; perversely, women who stop work to breastfeed incur a financial penalty. A single metric incorporating the negative impacts of products and services on population health, and the positive impacts of healthy pregnancies  and childcare, would be a better biomarker of a country’s wellbeing than GDP, and a better metric upon which to base post-COVID recovery. There are other pressing reasons for a focus on MNCH. The economic models of the late 19th and 20th C were at odds with the great social movements that arose in parallel, which included women’s suffrage, and reproductive and child rights. The extractive economics implicit in these models perpetuated gender and age-based inequities, enabling some nations and a minority of the world’s population, to accumulate enormous wealth, while many billions remain impoverished. This conflict continues, exemplified for example by the undermining of the World Health Organisation, the promotion of marketised healthcare, and the resistance to healthcare reform in the United States, conditions that amplify gender and age-based inequities. Initial responses to COVID-19 are widening them still further. Thus, in the UK, conventional economic thinking led to spending over £400m on stimulating consumption, reopening pubs and restaurants before schools and the US Census Bureau reports that working mothers have had to withstand the worst of COVID-19 restrictions. The realisation that many pre-COVID industries are unsustainable should be a trigger to rethink the value to societies of healthy women and children, and promote this through targeted investment.  Advocating for investment in MNCH is not new, but discourse to date has been limited on four principal counts. First, most suggested interventions centre upon medical constructs - clinic visits, screening, identification, and treatments - that ignore the wider environmental, attitudinal and socio-economic determinants of MNCH. Second, the justifications for investment in MNCH have focussed predominantly on short-term outcomes, such as infant mortality and morbidity, rather than the longer term and trans-generational benefits to population health and the economy. Third, as explained above, many activities that benefit Page 4 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Confidential: For Review OnlyMNCH are unmeasured, and hence unrecognised and unvalued; for example the inclusion of unpaid household work alone - which sustains the remunerated industries - would increase GDP from between 15% to 70% depending on the country and method of calculation (6). Fourth, the science of the developmental origins of health and disease has advanced from epidemiological associations that provided a limited basis for policy to detailed understanding of causal pathways from exposures and experiences in early life to later health or disease. In 1855 Frederick Douglass, a former slave said, “It is easier to grow strong children than to repair broken men”, a prescient articulation of the scientific basis for focussing policies on MNCH. Yet, in what future generations will see as unimaginable folly, current economic thinking discounts and in many respects actively detracts from MNCH. It is time to take stock and to take action to promote investment in MNCH at both individual and societal levels (7). Societies with the best chance of a strong future will be those with healthy populations that have resilience to future shocks. This means ascribing value to and investing in MNCH. There are many powerful policies to consider. Six months statutory paid leave on a “use it or lose it” basis for each parent in a child’s first year would improve breastfeeding, family cohesion and gender equity. Targeted parenting support and skills training would benefit children directly and reduce the substantial economic cost of maltreatment. Universal national health care systems would eliminate the hefty transactional costs and inherent inequities of marketised models that disproportionately disadvantage women and children. A global road map for universal education would empower billions, particularly girls, and reduce crippling personal and national dependencies. These proposals will appear unattainable to many and will be countered and fought, as was every great movement in history. Investing in MNCH, as a prime strategy for post-COVID recovery is not only the right thing to do; it also provides unique opportunity to reframe economic thinking for a sustainable future. We ask readers to call on their professional organisations and parent and family advocacy groups, to promote investments to policy-makers that target MNCH. Competing interest statementNM is immediate past-president of the UK Royal College of Paediatrics and Child Health and current president of the UK Medical Women’s Federation; the views expressed are her own.Page 5 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Confidential: For Review Only1) Gluckman PD, Hanson MA, Beedle AS. Early life events and their consequences for later disease: a life history and evolutionary perspective. American Journal of Human Biology. 2007 Jan; 19(1):1-9. 2) Parkinson JRC, Emsley R, Tarry Adkins JL, Longford N, Ozanne SE, Holmes E, Modi N Clinical and molecular evidence of accelerated ageing following very preterm birth Pediatr Res 125 2020; 87(6):1005-1010 3) Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, Landoulsi S, Jampathong N,  Kongwattanakul K, Laopaiboon M, Lewis C, Rattanakanokcha S, Teng DN, Thinkhamrop J, Watananirun K, Zhang J, Zhou W, Gülmezogl AM. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Global Health 2019 Vol 7  January 2019 e374) Desyibelew HD,  Dadi AF Burden and determinants of malnutrition among pregnant women in Africa: A systematic review and meta-analysis PLoS One.2019; 14(9): e0221712 5) Deaton A, Beyond GDP; American Economic Association meeting, San Diego, January 2020 http://www.princeton.edu/~deaton/downloads/Beyond%20GDP.pdf; last accessed Sept 128 14th 2020 6) Van de Ven P, Zwijnenburg J, De Queljoe M, OECD Statistics and Data Directorate; Including unpaid household activities: An estimate of its impact on macro-economic indicators in the  G7 economies and the way forward; Working paper No.91; 25th July 1918; https://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=SDD/DOC(2018)4&docLanguage=En; last accessed 14 Sept 20207) Jacob CM, Briana DD, Di Renzo GC, Modi N, Bustreo F, Conti G, Malamitsi-Puchner A, Hanson M. Building resilient societies after COVID-19: the case for investing in maternal, neonatal, and child health. The Lancet Public Health. 2020. 5 (11) e624-e627Page 6 of 5https://mc.manuscriptcentral.com/adcArchives of Disease in Childhood123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

Post-COVID economic recovery: women and children first … or last?

https://discovery.ucl.ac.uk/10139747/1/Conti_archdischild-2020-320898.R2_Proof_hi%20REVISION%20SUBMITTED%20080121.pdf

Post-COVID economic recovery: women and children first … or last?

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