The Issue. Disparities and inequities characterize the health and social well-being of children in the United States and the United Kingdom. Children’s rights and the United Nations Convention on the Rights of the Child are among the most powerful tools available to respond to and increase the relevance of pediatrics to contemporary disparities and determinants of child health outcomes. The articles of the convention establish the framework for a redefinition of what constitutes child health. The convention establishes a template for child advocacy, a matrix for establishing new approaches to health services, a curriculum for professional education, and a set of challenges for future child health outcomes and health systems research.
- health disparities
- child health outcomes
- professional education
- children’s rights
- health systems research
RELEVANCE OF THE UNITED NATIONS CONVENTION ON THE RIGHTS OF THE CHILD TO CHILD HEALTH
The importance of the United Nations (UN) Convention on the Rights of the Child is derived from the legal and ethical precedent that it establishes for children. It is the first and only legal document in the United States and the United Kingdom to assert a full array of rights that are inherently due to children. Under the auspices of this Equity Project, the American Academy of Pediatrics (AAP) and the Royal College of Paediatrics and Child Health (RCPCH) should work together to expand educational programs and resident training in children’s rights, implement national initiatives, and use their professional capital to influence professional organizations and societies to use the convention and children’s rights as tools to improve the global health of children.
As nations, the United States and the United Kingdom venerate and romanticize childhood, while at the same time, we abuse, molest, incarcerate, subjugate, segregate, and exploit our children. Although glorifying the developmental state that we call childhood in the abstract, we have as societies done much to eliminate it as a reality for many communities of children in our countries. As a result, gross inequities and disparities define the epidemiology of child health in both the United States and the United Kingdom.
The social, economic, and political environments in which children live and develop are increasingly being recognized as the most important contemporary determinants of child health. Ensuring children’s rights and use of the UN Convention on the Rights of the Child are among the most powerful tools available to respond to these contemporary determinants to improve the well-being of children. Pediatricians and pediatrics have an opportunity and must play a leadership role in responding to this “new, new morbidity” if all children in our respective countries are to have equal opportunities to thrive. At stake is the very relevance of pediatrics to child health.
Much data legitimize these perspectives. Although consideration of these statistics in isolation is important to an understanding of child health, comparisons of the regional, national, and international health status of subpopulations of children provide greater insight into child health and the pathophysiology of childhood disease. These comparisons reveal the significant disparities and inequities that currently exist among groups of children within our respective countries. In fact, these disparities and inequities define the health of our communities.
In a fiercely individualistic, antisocialist country such as the United States and, to a lesser extent, the United Kingdom, this is not to say that all must be equal. It is to say, however, that we must at some point be judged by the inequalities that exist in the social, economic, and political systems necessary to ensure opportunities for child health.
What are the requirements necessary to ensure equality of opportunity for health? How relevant are social, economic, and political determinants to the health of our children? How do we define health—using a traditional medical model or an expanded definition similar to the World Health Organization definition of health? How do contemporary roles of pediatrics and pediatricians relate to these critical determinants, and what will be their roles in the future? These are the research questions that must be answered if we are to deal with the disparities in health that challenge our children and communities.
The articles of the UN Convention on the Rights of the Child establish the framework to redefine the determinants of child health. They establish process and outcome measures for gauging our progress toward this end. A focus on child rights as a strategy to establish absolute gains and equity in child health outcomes is a paradigm change from the current practice of pediatrics. The convention establishes a template for child advocacy, a matrix for establishing new approaches to health services, a curriculum for professional education, and a set of challenges for future child health outcomes and systems research. It establishes a template for interdisciplinary collaboration in health services, professional education, and research and a common point of reference for all nations.
FOUNDATION OF CHILDREN’S RIGHTS
The importance of the convention is derived from the legal and ethical precedent that it establishes for children. It is the first and only legal document to assert a full array of rights that are inherently due to children. It is the world’s first and only universally accepted human rights document. It is the strongest foundation that we have as communities, professionals, parents, advocates, and educators to support our individual and societal efforts on behalf of children. It establishes the rights of children as coequal to those extended to adults. The potential use of the convention to improve child health is sufficient to warrant an honest and in-depth review by the AAP and the RCPCH of the relevance of children’s rights and the convention to the practice of pediatrics and child health outcomes.
With respect to the US legal system, there are an expansive number of federal, state, and local laws dealing with children. These laws, however, are framed primarily in terms of child protection—protecting children from exploitation and abuse; ensuring their best interests in family issues, educational programs, and health systems; and protecting the few legal entitlements that are extended to them. These “protective” measures are uncomfortably reminiscent of similar US laws that have in the past related to women and slaves—laws that emanate from the need to protect property and the “property rights” of “legitimate” members of society. We have a legal system that has promulgated a large patchwork of laws to protect children but relatively few that define their fundamental rights and establish measures to protect them.
The distinction here is crucial to understanding the importance of the convention and child rights to child health outcomes. Laws that protect rights are fundamentally different from those that extend privileges that can and often are revoked by executive and/or legislative actions. The suffrage and civil rights movements are examples of historical efforts to extend human rights to populations of US citizens who had been previously denied them. This has not yet occurred for children in the United States. They remain mired in a system that provides them limited protections and entitlements, reflecting their historical status as “property.” The UN Convention on the Rights of the Child establishes the legal basis for extending human rights to children. It establishes a concrete foundation for child advocacy and defines the social systems that are required to protect their rights.
If advocacy and action for children are not currently derived from a set of inherent legal rights, then is there a religious and/or ethical foundation for these rights? Starting from the Ten Commandments and continuing through the Old and New Testaments and the bodies of religious laws and interpretations that accompany them, there are relatively few religious tenets that speak to the sanctity of children and childhood and prescribe rights that are due them.
Without a firm legal, religious, moral, and/or ethical basis to ground our advocacy and programs for children, it will be difficult to achieve equity in child health outcomes. Perceptions that there is a high value and esteem extended to children and childhood in the United States and the United Kingdom are myths not supported by policy or status quo. That the United States is the only government in the world that has not ratified the convention lends credence to the low esteem that children are extended in the United States. The UN Convention on the Rights of the Child is the single most important tool that we have in the United States and the United Kingdom and around the world to deal with the critical contemporary determinants impacting child health outcomes.
TRANSLATING CHILDREN’S RIGHTS INTO IMPROVED HEALTH OUTCOMES
A review of the articles of the convention will clarify how the rights defined by them relate to child health and the activities of the AAP, the RCPCH, and other professional societies. The convention obligates states to ensure that each child is provided a litany of irrevocable rights, is protected from the vulnerabilities of being a child, and has opportunities to participate in the world within the context of their developmental and intellectual competencies. It challenges physicians to engage and respond to the World Health Organization’s definition of health as a “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
The convention establishes the ultimate responsibility of all governments, institutions, and the family to ensure that these rights are respected and that all actions dealing with children are performed in their best interests (articles 2–4). With respect to pediatricians:
The rights afforded to children for survival, development, and health care (articles 6 and 24), education (articles 28 and 29), and a standard of living adequate for physical, mental, and social development (articles 26 and 27) establish an expanded set of obligations for child advocacy.
The definition of an explicit set of rights for the vulnerable child—children who are or have been orphaned, adopted, refugee, disabled, and abused (articles 20–23 and 37), including responsibility for rehabilitative care (article 39)—expand the expertise required of all primary child health professionals:
The rights of protection from maltreatment and neglect (article 19) and from all forms of exploitation, including child labor, drug abuse, sexual exploitation, abduction, and in the juvenile justice system (articles 32–36 and 40), confirm and extend the pediatrician’s role in ensuring the child’s physical and social well-being.
The child’s rights, within the context of their competencies and family, to form and express an opinion, associate with peers, enjoy freedom of thought and conscience, maintain privacy, and have access to appropriate information (articles 12–17) contribute to an evolving child image of great relevance to pediatricians.
The rights of children to be free from all forms of discrimination (article 2); to a name, nationality, and identity (articles 7 and 8); and to enjoy and practice their own culture and religion relate to the challenges of US pediatricians to care for children in an increasingly diverse population.
The obligation of all parties at all times to act in the best interest of the child (article 3) and to provide families with the support and assistance that they require to fulfill their parental responsibilities, including access to child care services for working parents (article 18), define a set of standards to guide and support pediatricians and child advocates.
With respect to families, in firmly establishing the obligation of governments to respect the rights and duties of parents to raise their children and to provide the resources necessary for families to fulfill these responsibilities (articles 2, 5, 7–11, and 18), the convention provides pediatricians support for their historical focus and continuing efforts to support families.
POTENTIAL ROLES OF THE AAP AND THE RCPCH
The AAP, in collaboration with the RCPCH, can establish a global precedent for pediatrics in the implementation and monitoring of the convention. All pediatricians in all specialties should address children’s rights as part of the core work of the AAP and the RCPCH. Issues related to pain relief policies, respect for the child’s privacy, informed consent, and child involvement in medical decisions (including withdrawal of therapy) are child rights issues faced by all pediatricians, regardless of their specialty. The convention can provide the context for real child advocacy at the grassroots level, the framework for advocacy efforts by the AAP and the RCPCH and a tool for training current and future pediatricians as child advocates. Wales, for example, has used the convention to 1) establish a Commissioner for Children, 2) require all people who work with children to join a single Directorate, and 3) ensure that all programs that serve children are child focused.
If a new generation of child health professionals are to understand the critical issues affecting the health and well-being of children, then they must be educated early in their careers about children’s rights. They must be provided a language to use that is relevant and understandable to parents. Concerns of pediatricians, in particular those in the United States, related to the balance established by the convention between parental rights and children’s rights can be answered by increasing their breadth of knowledge about the focus of the convention on family and parents. This is important as the convention has the potential to facilitate advocacy in ways that have not been possible in the past. If we learn how to measure and evaluate the extent to which children’s rights are realized, then we may well have the kind of markers that can be translated into strategies and programs that address the critical determinants of child health. Use of the convention in these terms can provide the AAP and the RCPCH new perspectives and approaches to advocate for child health. With respect to the AAP and the RCPCH:
The AAP and the RCPCH should expand their educational programs on children’s rights. AAP sections, in addition to the Sections on International Child Health and Community Pediatrics, should be encouraged to develop educational programs on relevant aspects of children’s rights.
Committees on children’s rights should be established in both the AAP and the RCPCH.
The AAP Department of Community Pediatrics could implement a national children’s rights advocacy initiative and infuse consideration of children’s rights into its other endeavors. This would be particularly relevant to its Community Access to Child Health and Medical Home programs. With respect to the RCPCH, it could ensure that children’s rights become an integral part of the training of all pediatricians and that the RCPCH will work closely with other organizations to give children’s rights a priority consideration in government.
The Future of Pediatric Education II reassessment of undergraduate and graduate pediatric education provides an opportunity to include children’s rights as a strategy for child advocacy and accomplishing health outcomes. The AAP Washington office could similarly use children’s rights as a framework for its advocacy efforts.
The relationship between the AAP and the RCPCH to other professional and academic institutions in their respective countries (eg, the American Board of Pediatrics, Association of American Medical Colleges, National Academy of Sciences, Ambulatory Pediatric Association, and International Pediatric Association in the United States, and the Royal Colleges and Academy of Medical Colleges in the United Kingdom) could be used to engage partners in these efforts.
The AAP and the RCPCH could use their leadership and international links to establish the convention and children’s rights as critical tools to help improve the global health of children.
Integration of a children’s rights paradigm into pediatrics will continue the evolution that has characterized our profession since its inception. The convention speaks to a broad definition of health and an emerging image of childhood. The opportunity now exists for pediatricians to establish pediatrics as a rights-based profession and system of care. To do so will require a reformulation and expansion of the roles and functions of pediatricians.
As the effects of poverty and the child’s social and physical environment emerge as the most critical contemporary determinants of child health, the rights defined by the convention establish the essential conditions required by children to achieve a state of well-being. In this context, the promotion and protection of children’s rights must be inextricably linked to the work of all pediatricians to ensure the health of all children. The RCPCH and the AAP should now begin the translation of the tenets of the convention into reality for all children. The Equity Project provides a context and framework for this endeavor.
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- Convention on the Rights of the Child. UN GA Res 44/25. Available at: http://www.unhchr.ch/html/menu3/b/k2crc.htm. Accessed November 4, 2002
- Hodgkin R, Newell P, eds. Implementation Handbook for the Convention on the Rights of the Child. New York, NY: United Nations Children’s Fund; 1998
- International Covenant on Economic, Social and Cultural Rights. UN GA Res 2200A (XXI). Available at: http://www.unhchr.ch/html/menu3/b/a cescr.htm
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- Redress—international covenant on civil and political rights. United Nations General Assembly resolution 2200A (XXI). Available at: http://www.redress.org/uniccpr.html. Accessed November 4, 2002
- Universal declaration of human rights. December 10, 1948. UN GA Res 217A (III). Available at: http://www.udhr.org/UDHR/udhr.HTM. Accessed November 4, 2002
- Copyright © 2003 by the American Academy of Pediatrics