Lancet: Horton

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ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><FONT SIZE="2" COLOR="#FF6600" FACE="Arial" ><B> Lancet: Horton</B></FONT><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" >  </FONT></div> <div> <IMG SRC="3890e0e0.png" border=0 width="14" height="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"> <A HREF="id18.htm" TARGET="_top" TITLE="The Hospitals"><B>The Hospitals</B></A> </div> <div> <IMG SRC="3890e0e0.png" border=0 width="14" height="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"> <A HREF="id20.htm" TARGET="_top" TITLE="Photo Gallery"><B>Photo Gallery</B></A> </div> <div> <IMG SRC="3890e0e0.png" border=0 width="14" height="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"> <A HREF="id27.htm" TARGET="_top" TITLE="Contact the Trust"><B>Contact the Trust</B></A> </div> </td> <td valign="top" width="100%" style=" border-left: 1px solid #000000;" BGCOLOR="#FFFFFF" TEXT="#080000"> <div>  <script language="JavaScript1.2">  </script><script> if (document.all) document.write('<p align="center"</p><a href="javascript:addbookmark()">Click here to Bookmark this site!</a>') </script>  </div> <bR> <div> <TABLE BORDER="1" CELLPADDING="1" CELLSPACING="1" WIDTH="581" HEIGHT="1%" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" BGCOLOR=#FFFBF0 > <tR> <tD VALIGN=TOP HEIGHT= 70 ><NOBR><div> Beryl Thyer</div> <div> Memorial Africa Trust</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <bR> <bR> <div> Lancet: Horton</div> <bR> <div> The following Comment in a recent Lancet, written by the Editor, Richard Horton, is so clear and readable, and such a succinct review of what has been done and what will be done in neonatal and child health especially, that it is worth presenting in full to visitors to this site for their perusal. <I>The Lancet</I> will be giving progress reports over the next few months. This site will keep my visitors updated. </div> <div> <I>The Lancet</I> 2006; <B>367</B>:3-5</div> <div> DOI:10.1016/S0140-6736(06)67899-9</div> <div> The coming decade for global action on child health </div> <div> Richard Horton</div> <div> A new year brings new leadership to tackle the still appallingly high and largely preventable toll of child, newborn, and maternal deaths worldwide. Dr Francisco Songane, an obstetrician and former minister of health in Mozambique, has been appointed to head the Partnership for Maternal, Newborn, and Child Health. At the <I>Countdown to 2015</I> conference on Tracking Progress in Child Survival, held in London last month, Songane set out a compelling vision to intensify and harmonise national, regional and global action for children. His plan focuses on meeting two Millennium Development Goals (MDGs). MDG-4 calls for a reduction in under-5-mortality rates by two-thirds between 1990 and 2015. MDG-5 calls for a reduction in maternal mortality by three-quarters during the same period. These goals are tough but achievable.</div> <div> The <I>Countdown</I> conference arose out of a belief that children had fallen off the political agenda of international health. Over 10 million under-5 deaths had been ignored for far too long by governments and even international agencies. Children were invisible. Lacking votes, they had become marginal to the mainstream of political debate about human development. Three years ago, a group of concerned child health experts proposed not only to synthesise knowledge about child survival but also to catapult the child back onto the policy map of global health. They succeeded. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#1_" TITLE="Lancet: Horton"><B>1</B></A> </FONT>This work was followed by a similar concerted effort on newborn survival. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#2_" TITLE="Lancet: Horton"><B>2</B></A></FONT> The findings of both initiatives were later refined <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#3__" TITLE="Lancet: Horton"><B>3</B></A></FONT> and costed. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#4__" TITLE="Lancet: Horton"><B>4</B></A></FONT><B> </B>The results of intervention programmes began to be translated into practical policies. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#5__" TITLE="Lancet: Horton"><B>5</B></A></FONT></div> <div> The final paper of the first <I>Lancet</I> series <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#6_" TITLE="Lancet: Horton"><B>6</B></A></FONT> called for a mechanism to improve accountability, re-energise commitment, and recognise successes in child survival. To these ends, rotating 2-yearly conferences were proposed. The aim of the first of these <I>Countdown</I> meetings was to present coverage data on 19 indicators of progress towards MDG-4 (<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#panel_1" TITLE="Lancet: Horton"><B>panel 1</B></A></FONT>). These indicators were grouped into five themes: nutrition, vaccination, other preventive measures, newborn health, and case management. 60 priority countries that had the highest rates or numbers of under-5 mortality were identified. These 60 countries included over 90% of all deaths among children in the world today.</div> <div> <I><B> <A NAME="panel_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></I><FONT SIZE="4" COLOR="#0000FF" FACE="Arial" >Panel 1:</FONT><I><B> </B></I>Indicators for tracking child survival </div> <div> <B>Nutrition</B></div> <div> 1. Exclusive breastfeeding to 6 months</div> <div> 2. Breastfeeding and appropriate complementary feeding at 6-9 months</div> <div> 3. Continued breastfeeding at 20-23 months</div> <div> <B>Vaccination</B></div> <div> 4. Measles immunisation coverage</div> <div> 5. DPT3 immunisation coverage</div> <div> 6. Hib immunisation coverage</div> <div> <I><B> <A NAME="panel_2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></I><FONT SIZE="4" COLOR="#0000FF" FACE="Arial" >Panel 2:</FONT><B> </B><I>The Lancet</I> and child, newborn, and maternal survival </div> <div> <B>Prevention</B></div> <div> 7. Vitamin supplementation coverage with at least one dose in last 6 months</div> <div> 8. Access to safe drinking water</div> <div> 9. Access to sanitation facilities</div> <div> 10.<B> </B>Use of an insecticide-treated net for prevention of malaria</div> <div> <B>Newborn health</B></div> <div> 11. Skilled attendance at delivery</div> <div> 12. Tetanus toxoid protection at birth</div> <div> 13. Timely initiation of breastfeeding (within 1 hour)</div> <div> 14. Postnatal visit within 3 days after delivery</div> <div> 15. Prevention of mother-to-child transmission of HIV</div> <div> <B>Case management</B></div> <div> 16. Care seeking for pneumonia</div> <div> 17. Antibiotic treatment of pneumonia</div> <div> 18. Oral rehydration therapy and continued feeding received</div> <div> 19. Anti-malarial treatment</div> <div> Coverage data were next mapped onto these nations. The results reveal a mix of good and bad news. 7 nations are currently on track to meet MDG-4. However, 19 countries are in crisis-that is, they have either static or worsening under-5-mortality rates. The rest are showing some signs of progress, although coverage with effective interventions remains worryingly low. One purpose of the <I>Countdown</I> meeting was to identify accomplishments. For example, Senegal, Nepal, Bolivia, Tanzania, Pakistan, and Zambia have all shown encouraging successes. Their experiences need to be documented carefully and the lessons learned.</div> <div> The findings of the <I>Countdown</I> analysis provide an early warning signal to all those concerned with child health. None of the 60 priority countries has achieved even minimum coverage for all or most indicators of child survival. Children from the poorest families in each country suffer most of all. A huge amount therefore needs to be done to accelerate progress to MDG-4: too many children are dying unnecessarily while governments fail to take the actions needed to protect future generations. These countries cannot succeed on their own. They need help. There are strong signals that this help is at hand.</div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >WHO has renewed its concern with child and maternal health in substantive ways.</FONT> <A HREF="#7_" TITLE="Lancet: Horton"><B>7</B></A><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B>The agency dedicated its 2005 World Health Report to child and maternal survival. </FONT><A HREF="#8__" TITLE="Lancet: Horton"><B>8</B></A> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >And WHO cites “scaling up services for mothers and babies during delivery and after birth” as a key aim of its programme of work between now and 2015. UNICEF too has emerged under new leadership as a crucial protagonist for child survival. This commitment was not always assured.</FONT> <A HREF="#9_" TITLE="Lancet: Horton"><B>9</B></A><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> </B>Yet UNICEF's new executive director, Ann Veneman, has pledged the agency to what amounts to a second child survival revolution. Her vision is to use “sound science” to expand dramatically an integrated approach to child health. The latest State of the World's Children report </FONT><A HREF="#10__" TITLE="Lancet: Horton"><B>10</B></A> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >recommits UNICEF to MDG-4, draws attention to the exclusion of children from many of today's global debates, and presents a powerful analysis of the causes of this systematic exclusion and the ways in which it can be overcome.</FONT></div> <div> One cause of this more favourable environment for child health is the understanding that investments in children bring important economic rewards. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#11_" TITLE="Lancet: Horton"><B>11</B></A></FONT> Advocacy does not have to rest on appeals to moral leadership and compassion alone, important though these are. Surviving and healthy children are a pre-requisite for productive adults. When combined with good education, programmes for child survival are engines for poverty reduction. It is this kind of new knowledge that is shaping decisions by previously sceptical funders and foundations. The World Bank sees high economic returns, for example, from investments to reduce childhood malnutrition.<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#12_" TITLE="Lancet: Horton"><B>12</B></A><A HREF="#12_" TITLE="Lancet: Horton"> </A></FONT>The Gates Foundation recently announced grants of over US$84 million for newborn health. And the Global Alliance on Vaccines and Immunization (GAVI) has decided to invest in health-systems strengthening as a means to achieve and sustain its programmes of immunisation coverage. New political will to make child health a priority at country level is also appearing. Nowhere was this better exemplified than in the recent joint statement by the Prime Ministers of Senegal and Madagascar. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#13__" TITLE="Lancet: Horton"><B>13</B></A></FONT>  The Norwegian government has led higher-income nations by announcing its “ambition to take a leading role in making MDG-4 a reality”. Norway's Prime Minister,  Jens Stoltenberg has backed up this promise with a commitment to invest US$1 billion in GAVI through to 2015.</div> <div> There remain reasons to temper this optimism with caution. First, we should not be misled by the rhetoric of partnership. Although the new Partnership for Maternal, Newborn, and Child Health is welcome and much needed, it must quickly establish its comparative advantage alongside other agencies. Precise short-to-medium term objectives must be set out in a strategic plan to attract investment by donors. In particular, this new partnership has to be a critical friend to those existing bodies concerned with child and maternal survival. It must be inclusive but not compliant. It must stretch its partners to go beyond what each could have achieved by working alone.</div> <div> Second, we must not take our eyes off the very clear and measurable targets before us-namely, the mortality end points of MDGs 4 and 5. In debating how to take the child survival agenda forward, it is tempting to include broader issues such as human rights, fair trade, and democratic reform. It is also tempting to offer sharp critiques of, among others, the World Bank and the World Trade Organisation. But what then begins as a set of definable interventions to be rolled out in achievable ways to priority countries through virtuous collaborations quickly evolves into an unrealistic and ideological programme to reinvent the world. This kind of “mission creep” would be a serious mistake. Instead, all parties working towards child and maternal survival should encourage one another to focus on results and results alone. We should not let our wish for the ideal of a continuum of care from mother to child in a perfect health system become an excuse for compromise and delay.</div> <div> Third, we need to strengthen the science base of child and maternal health. This strengthening of research needs new money. But it also needs new attitudes. Obstetric and paediatric organisations from high- income countries must do more to build collaborations with colleagues in lower-income settings. Their passivity has contributed to the marginalisation of child and maternal survival from the global political agenda.</div> <div> <FONT SIZE="3" COLOR="#000000" FACE="Arial" >Finally, those of us who work at medical journals-and in the news media more generally-can do a great deal to draw attention to what are still neglected issues of child and maternal health next to, for example, AIDS, malaria, and tuberculosis. There are currently huge and inequitable imbalances in research publications between high and low income countries. </FONT><A HREF="#14_" TITLE="Lancet: Horton"><B>14</B></A><B> </B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >Journals, general and specialised, have an important part to play in shaping the views and behaviours of scientists, clinicians, and policymakers about issues of urgent global concern. We can be a vital bridge between these often disconnected communities (</FONT><A HREF="#panel_2" TITLE="Lancet: Horton"><B>panel 2</B></A><FONT SIZE="3" COLOR="#000000" FACE="Arial" >). </FONT><A HREF="#15__" TITLE="Lancet: Horton"><B>15</B></A></div> <div> One medical journal is only one medical journal. But as a positive partner with international agencies, academic institutions, the non-governmental sector, and countries, journals can act with others as catalysts for changing policymakers' and public attitudes to the global crisis in child and maternal survival. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#17__" TITLE="Lancet: Horton"><B>17</B></A></FONT><B> </B>We plan to make the next ten years to 2015-the MDG target date-a decade for the child in <I>The Lancet</I>'s work. We will take every opportunity to select, commission, and publish reliable and rigorously peer-reviewed work on all aspects of child and maternal survival to meet the needs of clinicians, public-health workers, and policy-decision makers worldwide. We are currently planning series on maternal survival, sexual and reproductive health, and child nutrition. The full results of the <I>Countdown</I> analyses will be published later this year.</div> <div> The challenge remains to think big, to persuade Prime Ministers and Presidents from richer nations to spend more time and resources on child and maternal health. The moral and instrumental arguments are all there. But, collectively, we have still failed to make the case at the highest political levels. A new Global Fund is one proposal that merits further discussion. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="#16__" TITLE="Lancet: Horton"><B>16</B></A> </FONT>Or perhaps a mechanism such as the International Finance Facility for Immunisation is a better model. Whatever option is chosen, advocates for child and maternal survival need to translate their passion into measurable achievements, nationally and globally. That will be the ultimate test of the <I>Countdown</I> when it convenes again in 2 years' time.</div> <div> The Countdown to 2015 organising committee included Flavia Bustreo (WHO/ World Bank), Simon Cousens (London School of Hygiene and Tropical Medicine), Bernadette Daelmans (WHO), Richard Horton (<I>The Lancet</I>), Betty Kirkwood (LSHTM), Regina Keith (Save the Children UK), and Elizabeth Mason (WHO). The Countdown Working Group on Coverage Monitoring included Nancy Terreri (UNICEF), Jennifer Bryce (UNICEF consultant), Tessa Wardlaw (UNICEF), Cesar Victora (University of Pelotas), Ron Waldman (Columbia University), Norma Wilson (Health Metrics Network), and Jasmina Acimovich (UNICEF). Thanks also go to Andy Haines and his colleagues at the London School of Hygiene and Tropical Medicine for hosting the first Countdown conference; to USAID, DFID, BASICS, and Save the Children for additional funding; and to Zulfiqar Bhutta, Robert Black, Anthony Costello, Joy Lawn, Anne Mills, Diana Silimperi, and Pascal Villeneuve for especially substantial inputs to the meeting.</div> <div> <B>References:</B></div> <div> <B> <A NAME="1_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>1.</B> </FONT> Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year?. <I>Lancet</I> 2003;<B> 301:</B> 2226-2234. </div> <div> <B> <A NAME="2_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>2.</B> </FONT> Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why?. <I>Lancet</I> 2005;<B> 365:</B> 891-900. </div> <div> <B> <A NAME="3__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>3.</B> </FONT> Bryce J, Boschi-Pinto C, Shibuya K, Black RE, et al. WHO estimates of the causes of death in children. <I>Lancet</I> 2005;<B> 365:</B> 1147-1152. </div> <div> <B> <A NAME="4__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>4.</B></FONT>  Bryce J, Black RE, Walker N, Bhutta ZA, Lawn JE, Steketee RW. Can the world afford to save the lives of 6 million children each year?. <I>Lancet</I> 2005;<B> 365:</B> 2193-2200. </div> <div> <B> <A NAME="5__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>5.</B></FONT><B> </B> Bryce J, Victora CG, Habicht J-P, et al. Programmatic pathways to child survival: results of a multicountry evaluation of IMCI. <I>Health Policy Plan</I> 2005;<B> 20</B> (suppl S1): i5-i17. </div> <div> <B> <A NAME="6_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>6.</B></FONT>  The Bellagio Study Group on Child Survival. Knowledge into action for child survival. <I>Lancet</I> 2003;<B> 362:</B> 323-327. </div> <div> <B> <A NAME="7_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>7.</B></FONT><B> </B> Lee JW. Child survival: a global health challenge. <I>Lancet</I> 2003;<B> 362:</B> 262. </div> <div> <B> <A NAME="8__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>8. </B></FONT> World Health Report 2005. Make every mother and child count. Geneva: WHO, 2005.</div> <div> <B> <A NAME="9_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>9.</B></FONT> Horton R. UNICEF leadership 2005-2015: a call for strategic change. <I>Lancet</I> 2004;<B> 364:</B> 2071-2074. </div> <div> <B> <A NAME="10__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>10.</B></FONT><B> </B>The State of the World's Children 2006. New York: UNICEF, 2005. </div> <div> <B> <A NAME="11_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>11.</B></FONT> Belli PC, Bustreo F, Preker A. Investing in children's health: what are the economic benefits?. <I>Bull WHO</I> 2005;<B> 83:</B> 777-784. </div> <div> <B> <A NAME="12_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>12.</B></FONT><B> </B>The World Bank. Repositioning nutrition as central to development: a strategy for large-scale actionWashington: World Bank, 2006.</div> <div> <B> <A NAME="14_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>14.</B></FONT> Paraje G, Sadana R, Karam G. Increasing international gaps in health-related publications. <I>Science</I> 2005;<B> 308:</B> 959-960. </div> <div> <B> <A NAME="15__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>15.</B></FONT> Choi BCK, Pang T, Lin L, et al. Can scientists and policy makers work together?. <I>J Epidemiol Community Health</I> 2005;<B> 59:</B> 632-637. </div> <div> <B> <A NAME="16__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>16. </B></FONT>Costello A, Osrin D. The case for a new Global Fund for maternal, neonatal and child survival. <I>Lancet</I> 2005;<B> 366:</B> 603-605. </div> <div> <B> <A NAME="17__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>17.</B></FONT> Horton R. Newborn survival: putting children at the centre. <I>Lancet</I> 2005;<B> 365:</B> 821-822.</div> <div> <B>Uncited Reference</B><B>:</B></div> <div> <B> <A NAME="13__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>13.</B></FONT> Sall M, Sylla J. African Prime Ministers take lead in child survival. <I>Lancet</I> 2005;<B> 366:</B> 1988-1989. </div> <bR> <div> <B>(Lancet: Horton)</B></div> <DIV ALIGN="LEFT"></DIV> <div>     <FONT SIZE="2" COLOR="#FF0000" FACE="Arial" ><A HREF="id17_m.htm" TITLE="Lancet: Horton">top of the page</A></FONT></div> <div> Beryl Thyer Memorial Africa Trust, a UK registered charity  ~  1112603</div> <bR> <bR> </td> </tr></table></body>