Education or Health? Either or?

The recent UNESCO EFA-report states that in 2012 6.6 million children died before their 5th birthday. The report also points out that education is one of the most powerful ways of improving people’s health. Most of the world agrees on the benefits of education. And according to the Millennium Development Goals universal primary education should be a fact by 2015. Sadly, this will not be the case.

Photo and text by Mette Holm

200 years ago, in 1814, Denmark introduced primary education for all. Denmark was among the very first countries in Europe to introduce seven years of free, compulsory education for all children. There were two classes, one for children of 7-10 years and one for 11-14 year olds. One such class would hold up to 50 pupils; the subjects were Christianity, reading, writing and arithmetic, the educational principle was learning by heart. Much has changed and improved since then – in Denmark that is. Compulsory education is now nine years; the subjects have multiplied to a much wider range, and no more than 28 pupils in each class.

Thus, we can congratulate ourselves in this tiny kingdom. But as we, in Denmark, celebrate this exemplary bicentennial millions of children still don’t enjoy that privilege. 57 million to be exact!

Barring only the most severe extremists, most of the world agrees on the benefits of education. And according to the Millennium Development Goals universal primary education should be a fact by next year, 2015. Sadly, this will not be the case.

It is not for lack of evidence of the benefits of education that the goal will not be reached. Never the less, according to UNESCO’s recent Education for All Global Monitoring Report 2013/14: Teaching and Learning: Achieving quality for all universal basic education is underfunded by 26 billion US-dollars annually – and aid for education is declining.

On the other hand, what’s so smart about education for all?

Everything’s smart about school!
Educate mothers and you empower women and save women’s lives. Educate communities, and you transform societies into growing economies. This is common knowledge, and also backed by endless research.

I remember vividly my visit in 1995 to Village no. 7 in Thuy Dong in coastal Tai Binh Province in Northern Vietnam, a poverty stricken area where children – as well as their parents – were under- and also malnourished. The most common diseases were pneumonia, diarrhoea and stomach pains. The inhabitants of Village no. 7 had long since felled the mangrove that provided varied and healthy food – as well as vital protection against the massive destruction of seasonal typhoons, which thus, they were now prey to.

I remember the woman who had to prioritise to raise her oldest son and daughter healthy and fed, sacrificing in the process her younger daughter’s health. She was not an evil woman. But her situation demanded that she make the evil choice – which no parent should ever have to make – of whether to raise three children in bad health or only one. I remember the parents that grew and sold vegetables at the market, spending their small income mostly on antibiotics for their three children who suffered a myriad of diseases, and were weakly and ailing. I remember the woman, who raised chicken and sold all the eggs at the market to earn cash; she, too had high medical costs for her kids, even if the other villagers deemed her family “the richest among the poor”.

I visited Village no. 7 with Vietnamese and Danish Red Cross, and their approach was confoundingly simple: with just a few brief courses and workshops on health, economic aid to re-establish the mangrove, and the introduction of simple latrines, life in the village turned from destitution to a functioning community with haggling at the market, a rising number of hygienic latrines and energetic children in school; their mothers happily attending weekly voluntary education on nutrition and very basic household economics.

By keeping rather than selling one egg a week for each child, the chicken-raising family no longer needed to spend much on medicine, and the children gained strength and energy. The three eggs were much less of an expense than the medicine.

One could hardly think of a better return of Red Cross’ relatively small investment than developments in Village no. 7: I don’t remember the actual cost. But cash costs were for the re-establishment of the mangrove, which soon protected the village from severe flooding and provided varied and healthy nourishment for the community, e.g. honey and shrimp; as well as simple construction materials for latrines, which were an immense improvement to hygiene and thus health in the village. And then there was the training of local trainers to educate the families on nutrition and how to make the most of what they had.

Education saves lives

Vietnam has had compulsory primary education for years, but it has been difficult to uphold in inaccessible mountain areas. One such village was Van Ho, remote and inaccessible in every sense, home in the late 1990es to 16 families, a total of 120 people, of the Red Dao ethnic minority. The village had a small school in a straw hut; the voluntary teacher was a former veteran of Vietnam’s jungle war. I remember him clearly, because he had only one eye and only one arm. He was the only literate person in the village. He had 16 pupils, nine boys and seven girls in 1st and 2nd grade. The children spoke only their mother tongue. The teacher taught them in Vietnamese. Very few children went to school for more than three years. The nearest public school was more than six hours away, as was the clinic.

The Red Dao had a brilliant water supply system: hung high in the trees with liana, split bamboo pipes led fresh and pure water from the creek far above the buffaloes’ grazing areas and down into the village. Food – venison, cassava, rice, fruits and herbs of the jungle – was prepared in a wok inside the house over an open fire. No windows, only the door, in some instances two doors, and perhaps a small hole in the ceiling to let air in and smoke out.

The women gave birth (much too) frequently; some children survived, some didn’t, a fact of life. Their slash-and-burn traditional way of life was becoming obsolete, no longer sustainable, and they totally lacked the skills of modern life. They tried to raise ducks, and failed miserably. All the ducklings died.

We walked three hours on a narrow mountain path to reach the village of Van Ho. The villagers were wonderfully hospitable and showed deep and remarkable insight; they didn’t necessarily understand the exact causes of changes that went on around them climatically, economically and socially, but both women and men clearly understood that they needed new knowledge and skills to adapt to the consequences in the immediate future. Their expertise in jungle living was no longer adequate.

These women who didn’t read and write, inquired about the possibility of learning how to plan a budget, how to make their resources last all through the year, so they – and their families – would not have to suffer scarcity and shortage two-three months every year. And earlier, despite a heavy taboo on sex and birth, they had asked Red Cross for advice on how to have fewer children. They didn’t want to see their children die, they wanted their children to live and to be able to care properly for each and every one of them, and thus they wanted fewer children with the prospect of more or all of them surviving.

The Red Cross-visit to Van Ho Village, which I had the privilege of joining, was the reaction to the women villagers’ request. So nurses set up a temporary clinic in the straw hut-school where the women could be fitted with IUDs. The women resolutely trotted down the hillside to the straw hut, and in view of the strict taboo demanding only that we, the strangers and the foreigner, didn’t look at them, when they passed us on their way to the hut and the business it entailed.

These examples sound too good to be true, but they aren’t. The point is that education is the prerequisite for the future, and that there is absolutely no excuse for not promoting and funding education for all. It is not very expensive – and it saves lives, agony and money in the long run.

Figures speak for themselves

The recent UNESCO EFA-report states that in 2012 6.6 million children died before their 5th birthday. Much better than 20 years before, but still not anywhere near good enough. Of the 43 countries where more than one in every 10 children never reach the age of five, only eight will reach the stated goal of reducing child deaths by two thirds from 1990 to 2015.

Remarkably, two of the poorer countries, Bangladesh and East Timor, have invested in early childhood interventions and thereby reduced child mortality by at least two thirds ahead of the target date. So it can be done.

The report points out that education is one of the most powerful ways of improving people’s health. Education saves millions of mothers’ and children’s lives, and as was the case for the villagers of Village no. 7 in Northern Vietnam, education helps prevent and contain disease and is vital to reducing malnutrition. And it provided a ticket to the future for the villagers in Van Ho.

Educated people are simply better informed about diseases, they are better at taking preventive measures, they recognise the signs of illness early and tend to use health care more often, when available.

The report gives ample proof that girls who go to school have fewer babies who stand a better chance of survival. Education of girls also leads to fewer child brides (under 15 years) and to fewer teenage mothers. As of now, in sub-Saharan Africa 3.5 million babies are born every year to mothers under 17 years.

And in sub-Saharan Africa women with no school education on average have 6.7 children. Women who have completed primary school have 5.8, while women who have also completed secondary school have 3.9 children.

Messrs John G Cleland and Jerome K van Ginneken in their 1988-report, Maternal Education and Child Survival in Developing Countries: the Search for Pathways of influence, presented a formula describing the relationship between mother’s education and child survival: on average each one-year increment of mother’s education corresponds with a 7-9% decline in under five-year olds’ mortality rate.

John Caldwell and Peter McDonald’s report, Influence of Maternal education on Infant and Child Mortality: Levels and Causes from 1982 concluded that more-educated mothers are more likely to receive pre-natal care and deliver their babies with the assistance of trained staff.

Also, more-educated women marry and enter into motherhood later and have fewer children who survive better. Maternal schooling proved a very strong and consistent predictor of reduced child mortality as well as morbidity. The two gentlemen concluded that in settings with a high degree of illiteracy, “improving health facilities should go hand in hand with educating women.”

And what must have appeared somewhat heretical at the time, they concluded that parental literacy was more important than both access to health and income factors. Caldwell and McDonald regarded maternal education as most essential, as it would also serve to break down traditional power and decision-making structures, which often disfavoured women and girls:

“Age and sex differentiations in power, decision-making and benefits within the larger family are reduced when schooling brings about a new family system in which women and children are allocated higher priorities in terms of allocation of food and in which parents can make decisions about health and child care without reference to their elders.” The more educated the mothers, the more they will demand that their children be cared for properly.

We have proof, what we need is action!

Proof abounds! Most recently the EFA-report comprehensively points out the enormous benefits from universal education, and the equally enormous dire consequences if this second Millennium Development Goal is ignored.
Universal literacy is fundamental to social and economic progress. Literacy skills are best developed in childhood through good quality education. Very few countries offer genuine second chances to illiterate adults, and thus are not able to eradicate illiteracy.

In 1999, 109 million children didn’t have access to primary education. In 2011, the figure had decreased to the numerically impressive 57 million. However, even if it is almost halved, 57 million children in our day and age without access to primary education, is hardly impressive. And proportionally, global illiteracy has only decreased by one per cent since 2000. The report says the 2nd MDG won’t be achieved by 2015 – one reason being the acute underfunding mentioned above.

Education ministers of The African Union met in Yaoundé, capital of Cameroon, in May. In rather vague terms they agreed on “bridging gaps” and “creating synergies in education policies in Africa” as an essential part of educating for “African renaissance towards 2063 Agenda” by which time education should become a pan African value. Commissioner of Human Resources Science and Technology of AU, dr. Martial De-Paul Ikounga pointed out the necessity to provide continual support to teacher development in order to enable them to train African students to become globally competitive.

Half of the 57 million children missing primary school in 2011 lived in conflict-afflicted countries, up from 42% in 2008. Only 23% of poor girls in rural areas in sub-Saharan Africa were completing primary school by 2010; and only in 2086 will the poorest girls catch up.

In 2011 there were 774 million illiterate adults in the world. The number is projected to fall slightly, to 743 million by 2015. Almost two thirds of illiterate adults are women. The poorest young women in the developing world may not achieve literacy until 2072.

Girls make up 54% of the global child population out of school. In the Arab states the proportion is 60%, unchanged since 2000. South and West Asia, by contrast, managed to steadily reduce the percentage of girls out of school from 64% in 1999 to 57% in 2011. Almost half of the children out of school globally will most likely never attend school. The same is true for almost two thirds of the girls in Arab States and sub-Saharan Africa.

Adult literacy rates since 1990 have increased faster in the Arab states than anywhere else. Nevertheless, simultaneous population growth has meant the number of illiterate adults has only fallen from 52 million to 48 million. In sub-Saharan Africa, the number of illiterate adults reached 182 million in 2011, a 37% increase since 1990. UNESCO projects that by 2015 26% of all illiterate adults will live in sub-Saharan Africa, up from 15% in 1990.

Laudably, since 2009 Vietnam, Laos and Rwanda achieved a minimum of 85% reduction in out-of-school population, the top three in this category.

We even know why!

One reason for the generally sorry state of affairs in universal primary education is the quality of education, i.e. teaching material and teachers’ education. According to the EFA-report, around 250 million children are not learning basic skills, even though half of them have spent four years in school.

Take, for instance, the one-armed, one-eyed teacher I met in the remote mountain village of Van Ho. He taught the children as best he could, he did it voluntarily, and because of all in the village he was the one who was best equipped for the job. But – like hundreds of thousands like him according to the EFA-report – he simply lacked the training to perform a decent job.

130 million of the 250 million children who cannot read, write or do basic mathematics actually attend school, but the level of education is lousy. The report concludes that if we are to improve opportunities for all these children, a shift towards improving the quality of education is central to the post-2015 global development framework.

26 countries in the report have a primary school pupil-teacher ratio of 40:1 or higher; 23 of these are in sub-Saharan Africa. Many countries try to make up for this deficit by simply hiring more teachers, or rather, more people to teach. This may increase school attendance and possibly also create a modest amount of jobs, but the report warns that it severely jeopardises the quality of education. The situation in secondary schools is only slightly better.

A convenient shortcut to Sustainable Development Goals?

Mobile phones are becoming ever more accessible, pricewise as well as logistically. While only 4.5 billion people in the world have access to a working toilet, six billion have access to a working mobile device. Africans are leading in doing business, banking and all sorts of other activities on their mobile phones. And other developing countries are hot on the heels of Africans mobile device proficiency.

Another recent UNESCO-report, Reading in the Mobile Era, encouragingly found that in countries where illiteracy rates are high and physical texts are scarce, large numbers of people read full-length books and stories on rudimentary small screen devices.

The report is the first of its kind; the survey was completed by over 4,000 people in Ethiopia, Ghana, India, Kenya, Nigeria, Pakistan and Zimbabwe and supported by qualitative interviews with numerous respondents.

Most people in sub-Saharan Africa do not own a book, and schools in the region rarely provide textbooks to pupils. Interestingly, the report shows that in areas where books are scarce, distribution poor and poverty abounds, mobile technology is increasingly common.

In areas with a high degree of illiteracy and difficult access to physical texts, mobile devices are a viable access to text. Downloading a mobile book costs 2-3 cents, while the same book in paperback costs 10 US-dollars.

The report’s main findings are:

  • One third of the study participants read stories to children form mobile phones.
  • Females read far more on mobile devices than males (almost six times as much).
  • Both men and women read more cumulatively when they start reading on a mobile device.
  • Many neo- and semi-literate people use their mobile phones to search for texts that are appropriate to their reading ability
  • Even though two thirds of the illiterate people in the world are women, women and girls read a lot more on the mobile devices, and the report suggests that improved access to mobile devices and ITC for girls and women would serve to strengthen their literacy immensely.

Thus, these mobile devices might provide a shortcut to education and general spreading of knowledge and texts, as it seems a viable way to improve education for all. Distance learning via the Internet is cheap and reaches far, whether it is primary or secondary school, higher learning or upgrading the knowledge and capacity of teachers or any other group.

Many of the world’s fines institutes of higher learning offer free courses in cyber space (called MOOC – Massive Open Online Courses) by their best capacities on a myriad of subjects.

In 2015 the new Sustainable Development Goals have to be set to continue the process of the MDGs that were to have been reached by 2015. MOOCs on small and simple devices might provide a viable shortcut to dissemination of information and education on a wide range of levels and subjects to the millions of people who suffer from lack of access to education, education material, texts and even news. Another obvious advantage is the possibility for the individual to study or read at your own convenience rather than a set time and venue, which might conflict with work or other chores.

Messrs Caldwell and McDonald came to the conclusion in 1982 that “it is wasteful to put large inputs into health services without putting equivalent inputs into education, especially that of girls.” This is not a question of promoting one at the expense of the other, but of forcefully promoting both. Health and education, particularly that of girls, go hand in hand as is now at least to some accepted knowledge, expressed in the multi-disciplinary approach to global health in the 21st century.

Mette Holm is an author and free lance journalist

The UNESCO reports can be found here:


1 comment

Morten Sodemann - 20. June 2014 Reply

We have known for decades that maternal school education can reduce overall child mortality in the poorest families by nearly 50 % – breast feeding also seems to be able to provide overall protect children from the poorest families from dying. These very broad interventions are able to do what some vaccines like the measles vaccine can. Maybe we should see maternal education, measles jabs, breast milk and impregnated bed nets as a package of interventions that immunize the poorest against the dangers of being poor.

We could add social capital to the package: in a study from Ethiopia of social determinants of health and social capital as risk factors for child mortality it was demonstrated that social capital had an independent protective effect.

But what is it about school education that protects against child deaths? We know something about it from studies in resource poor settings with high child mortality. Several of these studies were carried out in Africa over 25 years ago: Parents with school education would walk longer distances to see a doctor with their sick child. School education reduces resistance to changes in traditional beliefs and quicker adaptation to new ideas or interventions like birth control, immunizations or the benefit of school education. School education improves health literacy – the ability to seek, understand and use knowledge about health. School education expands the social network and increases the social capital outside the family offering better support outside the often weak possibilities to cope of poor families. An often overlooked but powerful effect of school education is that it improves strategic competencies and provides tools for financial planning – two competencies that in recent years have been shown to lack mainly in the poorest families. School education should be seen as a preventive primary health care intervention just as important as ante natal care, measles jabs – and vice versa: good parental and child health improves the effect of school education.

The Swedish SIDA funded school education in Guinea-Bissau until 1990 when they stopped all aid to the country. Since then the entire school sector has been stunned. Books were no longer printed, teachers were no longer offered proper training, teacher salaries are not paid and their housing in rural areas has deteriorated with the effect that there has been no functional school education in the entire country since 1990. At the same time the world bank has imposed school fees while food prices have rocketed sky high. Poor families have to priorities – they send children to school but only for a couple of years. Better off families send their children to one of the many private “schools” setup under a tree where a young man claiming to a teacher will teach 30 children in all ages. Limited school facilities has forced schools to have night classes – parents are horrified because the high risk of teenage pregnancies girls attending night school. Nobody from SIDA has bothered to evaluate the long term effect of leaving an entire country effectively without school education for 25 years. The first of these children are entering an adult life now and are supposed to take over business and public administration. We have only seen the tip of the ice berg of the effect of SIDA’s decision in Guinea-Bissau.

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