The Struggle for Children’s Health

It is simply no longer necessary,
and therefore no longer acceptable, for millions of families to
endure preventable disease and malnutrition and for millions of
their children to suffer frequent illness, poor growth,
and early death.
Through the lens of histo- ry, what is happening now in the developing world may come to be seen as the begin-
ning of a final offen-
sive against some of
the oldest and most
common enemies of
the world’s children.
The most important
aspect of this pro- A couple and their 11 chil
gress is the gradual
ascendancy that is being gained over the major diseases
of childhood.
The most devastating of those diseases is common
measles, a relatively minor illness in the industrialized
nations but a major cause of death, malnutrition, and
disability among the children of poor communities in
the developing world. Not much more than a decade
ago, approximately 75 million children contracted the
measles virus each year, and more than 2.5 million
died during the acute phase of the illness. Today,
thanks to improvements in health care and immuniza-
tion, measles cases have been reduced to approximate-
ly 25 million a year and deaths from the disease have
been cut to just over one million.’
This article is adapted from UNICEF’s annual report, The State of the World’s Children 1994 (Oxford University Press,1994).
dre
Second, significant
progress is also being
made against the
diarrheal diseases
that are among the
major causes of
stunted growth and
early death among
the children of poor
communities. In the
early 1980s, approxi-
mately four million
children a year were
n in Asunci6n, Paraguay. dying from diarrheal
disease. But since
1985, the technique of oral rehydration therapy (ORT)
has been put at the disposal of approximately 250 mil-
lion families or about one third of the developing
world’s children. Sixty countries now produce packets
of oral rehydration salts (ORS) according to the for-
mula developed by the World Health Organization
(WHO) and UNICEF, and more than two thirds of the
world’s population can obtain ORS within a reason-
able distance from their homes. 2 The result is the pre-
vention of more than a million deaths a year from diar-
rheal disease. 3
The 1980s and early 1990s have also seen the rais-
ing of immunization levels from under 20% to approx-
imately 80%-undoubtedly one of the greatest public-
health achievements of this or any other century. In
addition to its contribution to measles control, immu-
nization has also made major inroads into territories
VOL XXVII, No 6 MAY/JUNE 1994
k Y u
B z
35REPORT ON CHILDREN
formerly held by whooping cough, tetanus, diphtheria
and polio. At the beginning of the 1980s, whooping
cough was killing over 700,000 children a year; today
that toll has been reduced to approximately 400,000.4
Over the same period, the number of newborns dying
from neonatal tetanus has fallen from 1.1 million to
fewer than 600,000 and the number of children dying
from diphtheria has been cut from 19,000 to 4,000.5
resent a significant gain against the fundamental prob-
lems of malnutrition, and poor mental and physical
development.
Recent years have also seen steady progress in
extending safe water and sanitation to millions of fam-
ilies in the developing world. Since 1980, the propor-
tion of families with access to safe drinking water has
risen from 38% to 68% in South-East Asia, from 66%
TABLE #1
Infant/Maternal Health: Selected Countries
DPT is diphtheria, pertussis (whooping cough) and tetanus. ORT use rate is the per-
centage of all cases of diarrhea in children under five treated with oral rehydration
salts or an appropriate household solution. Maternal mortality rate is the number of
deaths of women from pregnancy-related causes per 100,000 live births. Contracep-
tive prevalence is the percentage of married women aged 15-49 currently using con-
traception.
% Fully Immunized
COUNTRY DPT Polio Measles
62
91
84
93
92
86
81
70
74
93
90
74
98
91
72
80
85
77
ORT Use Maternal Contraceptive
Rate Mortality Prevalence
63
10
40
80
63
40
31
NR
NR
Source: UNICEF, The State of the World’s Children 1994).
Also as a result of immunization efforts, polio has
been steadily giving ground. In 1980, almost 400,000
children were crippled for life by the polio virus. Last
year, its victims numbered approximately 140,000.6
According to WHO, there is now a reasonable chance
that polio can be eradicated from the face of the earth
by the year 2000.
A lesser-known benefit of progress in immunization
is its contribution to improved nutrition. Frequent ill-
nesses are a threat to a child’s nutritional health and
long-term growth: they reduce appetite for several
days at a time; they inhibit the absorption of food;
they consume calories in fevers and in fighting the dis-
ease; and they drain away nutrients in vomiting and
diarrhea. When such illnesses strike frequently, the
child is steadily pushed into a downward spiral of
malnutrition and ill health. And it is this spiral, rather
than any individual cause, which results in so many
millions of children failing to survive their early years
or failing to grow to their full mental and physical
potential. The major gains being made against specific
childhood diseases in recent years therefore also rep-
200
67
200
39
110
NR
300
66
43
66
70
53
27
59
5 73
8 74
York: Oxford University Press,
to 78% in Latin America,
and from 32% to 43% in
Africa. 7 Safe sanitation
has advanced more slow-
ly, but more than half of
all families in the devel-
oping world can now dis-
pose of feces safely. 8
These gains too have
made their contribution
to reducing the toll of
disease and improving
nutritional health.
Lastly, remarkable
progress has also been
made in extending the
knowledge and the
means of family plan-
ning. In three decades,
the number of children
born to the average
woman in the developing
world has fallen from 6.0
to 3.7. Overall, the pro-
nortion of married
women using modern methods of family planning has
increased from less than 10% to approximately 50%.9
The speed of this change is unprecedented in demo-
graphic history, with some 17 nations succeeding in
halving their fertility rates in only one generation. 10
Family planning is one of the most important of all
contributions to social and economic development: it
reduces the number of maternal deaths; it lowers
under-five mortality rates; it improves the nutritional
health of both women and children; it gives women
more health, more time, and more opportunity; it has a
positive impact on the care and education of children;
and it slows population growth. And even though
there is still a considerable unmet demand, the spread
of family planning constitutes one of the most signifi-
cant contributions to human well-being of recent
years.
dvances in knowledge and technology have
been necessary but not sufficient to bring
about these improvements. Most of the science
involved has, after all, been available for several
decades: ORT proved its large-scale effectiveness 25
years ago; the vaccines that have made possible recent
progress against measles, tetanus, whooping cough
and polio have been available since at least the 1960s;
most of the modern methods of contraception now in
widespread use have been available for 30 years; and
salt iodization was first used to overcome iodine-defi-
ciency disorders in Switzerland and the United States
during the 1920s. 1
The new element which has made possible the
recent mass application of these advances is a wider
social and economic change. That social change has
been of two main kinds. First, infrastructure and com-
munications capacity in most developing nations have
now reached the point at which it is physically and
financially possible to bring the basic benefits of sci-
entific progress to virtually every community. This is
a historic and much underestimated change, and its
potential has been forcefully demonstrated by the
immunization achievements of recent years. High lev-
els of immunization coverage in the developing world
indicate that a system is now in place-including a
capacity for training, supply, management, communi-
cations, delivery, and record-keeping-that is capable
of reaching out to over 100 million infants a year on
four or five separate occasions during their first year
of life. That outreach system, extending to almost
every rural hamlet and urban neighborhood, is very far
from being universally reliable, and it will require
extraordinary efforts to sustain and strengthen it in the
remaining years of the 1990s. Its achievements so far,
however, have shown that almost all developing
nations now have the capacity to put the basic benefits
of scientific progress at the disposal of almost all of
their people.
The second and related change is the rise in world-
wide public and political awareness that such
advances are now possible, that both the scientific knowledge and the outreach canaci-
TABLE #2
Malnutrition Indicators: Selected Cc
Infant and under-five mortality rates are the number of de
live births under the ages of one and five years respectively
weight is the percentage of children born weighing less th
(5.5 lbs.). Goiter rate is the percentage of children with go
of iodine deficiency which causes brain damage and ment
Infant Under-five Low
COUNTRY Mortality Mortality Birthweight
Brazil 54 65 11
Chile 15 18 7
Colombia 17 20 10
Cuba 10 11 8
Mexico 28 33 12
Nicaragua 54 76 15
Peru 46 65 11
Canada 7 8 6
USA 9 10 7
Source: UNICEF, The State of the World’s Children 1994 (New Yo University Press, 1994).
NACIA REPORT ON THE AMERICAS
ty are now available, and that it is
,untries simply no longer necessary, and therefore no longer acceptable, for aths per 1,000 millions of families to endure pre-
y. Low birth- ventable disease and malnutrition
an 2,500 grams and for millions of their children to iter, an indicator suffer frequent illness, poor growth, al retardation. and early death.
Goiter Rate This awareness has begun to
(6-11 years) translate itself into political pres- sures. An early example was the 14 commitment to the 80% immu-
9 nization goal made by almost all
10 national political leaders in the mid-
10 1980s. At that time, only a third of
15 the developing world’s children
4 were being immunized; just over
36 five years later, close to 80% were
NR being protected by vaccines.
NR At about the same time as the
immunization goal was being ork: Oxford reached, this process of widening
awareness and growing pressure for
action was leading to specific demands for other basic
benefits of progress to be made universally available.
To thousands of individuals and organizations all over
the world, it began to seem more and more of an out-
rage that something as simple, preventable, and treat-
able as ordinary diarrheal disease was still claiming
the lives of three million young children a year; or that
more than three million were being allowed to die
from respiratory infections when antibiotics could be
made available at almost negligible cost; or that the
world was still prepared to tolerate millions of deaths
a year from measles, whooping cough and tetanus
among the 20% of children who were still not being
reached by vaccines; or that poliomyelitis was still
being allowed to paralyze more than 100,000 children
a year when it had become possible to eradicate the
virus from the face of the earth.
As the 1980s progressed, a rapid expansion in
knowledge about the condition of children in develop-
ing countries began to add other issues to this list.
Why were a quarter of a million children a year being
allowed to go blind from the lack of vitamin A when it
was possible to make inexpensive vitamin A capsules
available to every child at risk? 1 2 Why was iodine
knowled,e and the outreach cqnaci-
38REPORT ON CHILDREN
deficiency still the leading cause of preventable men-
tal retardation in the world, causing over 100,000
infants to be born as cretins each year and affecting
the normal development of at least 50 million chil-
dren, when the problem could be prevented by some-
thing as affordable and manageable as iodizing all salt
supplies?’ 3 Why were an estimated one million babies
being allowed to die each year because of an almost
unchallenged decline in the practice of exclusive
breast feeding in many areas of the world? 1 4 And why
were nearly a million people still suffering the painful
and debilitating effects of guinea-worm disease when
the cost of control in affected areas had been reduced
to only about $2.50 per person?’ 5
Even areas in which steady progress had been made
began to be subjected to a more impatient questioning.
Why do a billion people still lack safe water when
new technologies and community-based strategies
have shown the way to solve this problem at much
reduced cost? 1 6 Why are a third of the developing
world’s children below an acceptable weight when
new approaches have demonstrated that malnutrition
can be very substantially reduced at a cost of less than
$10 per child?’ 7 Why do surveys show that one preg-
nancy in five in the developing world is unwanted
when today’s communications and outreach capacity
is clearly capable of putting the advantages of family
planning at the disposal of almost every couple?
In addition, questions were also being raised about
one subject which had received very little attention
and in which very little progress appeared to have
been made. Why, it was asked at the United Nations
Safe Motherhood Conference in 1989, were 500,000
young women still dying every year in childbirth in
the developing world? Why, for example, were
women in sub-Saharan Africa still facing a 1-in-20 risk
of dying in childbirth when the risk for a woman in
the industrialized world had been reduced to about 1
in 3,600?18
n the fall of 1990, this rising awareness of what
could be done culminated in the convening of the
first global summit ever held to discuss a major
social issue as opposed to political, military or eco-
nomic affairs. The World Summit for Children, held at
the United Nations in New York, was attended by rep-
resentatives of almost every nation, including 71 pres-
idents and prime ministers. Its aim was to consider a
broad range of advances that had been made possible
by progress in knowledge and technology, by reduc-
tions in costs, and by the increasing communications
capacity in the developing world. The result was a
range of new social goals and an agreement-now
signed by 159 countries–that each nation would
adapt the goals to its own circumstances and draw up
a national program of action for achieving the goals
by the year 2000.19
Briefly, those new goals include a one-third reduc-
tion in under-five mortality rates, the halving of child
TABLE #3
Access to Services: Selected Cc
All numbers are percentages of the pop
COUNTRY
Brazil
Chile
Colombia
Cuba
Mexico
Nicaragua
Peru
Access to
SAFE WATER
Urban Rural
95
100
87
100
81
76
77
61
NR
82
91
68
21
10
Access to
SANITATIO!
Urban Rura
84
100
84
100
70
78
77
price which could be easily afforded if even 20% of
present government spending in the developing
world, and 20% of overseas aid budgets, were to be
allocated to long-term investment in meeting basic
human needs for adequate nutrition, primary health
care, basic education, safe water supply, and family
planning. At present only about 10% of government spnendine and of overseas
countries
ulation.
Access to
32
20
18
68
17
NR
20
aid budgets is devoted to
these purposes.
Between September,
1990 and July, 1993, 86
governments have drawn
up national programs of
action for reaching the new
goals. These programs are
now being put into effect
with varying degrees of
commitment and funding.
Another 56 countries are in
the final stages of drawing
up such plans.
To maintain a sense of
urgency, most of the devel-
oping world’s govern-
ments have also agreed to
NR
NR
NR
99
80
100
NR
NR
NR
NR
96
60
60
NR
Source: UNICEF, The State of the World’s Children 1994 (New York: Oxford University Press, 1994).
malnutrition, the achievement of 90% immunization
coverage, the control of major childhood diseases, the
eradication of polio, the halving of maternal mortality
rates, a primary-school education for at least 80% of
children, the provision of safe water and sanitation for
all communities, and the making available of family-
planning information and services to all who need
them.
The total extra cost of reaching all of these year
2000 goals is estimated at approximately $25 billion a
year. This is a small price to pay for a program that
would effectively protect almost all the world’s chil-
dren from the worst effects of poverty. And it is a
try to reach a limited number of those goals by the
middle of the decade. Those 1995 targets include the
elimination of neonatal tetanus, a 95% reduction in
measles deaths, the promotion of ORT to 80% of the
developing world’s families, the observance of the
WHO/UNICEF code of practice on breast feeding in
the majority of hospitals and maternity units, the
elimination of guinea-worm disease, the eradication
of polio in selected countries, an end to vitamin A
deficiency on today’s scale, the universal iodization
of salt supplies, and the achievement of 80% immu-
nization levels in all countries that have not yet
reached that goal.
The Struggle for Children’s Health
1. United Nations Children’s Fund (UNICEF), The State of the World’s Children 1993 (New York: UNICEF, 1993), p. 5.
2. Dialogue on Diarrhoea, No. 52 (March-May, 1993).
3. World Health Organization (WHO), Programme for Control of Diarrhoeal Diseases, Interim Programme Report 1992 (Geneva, Switzerland: WHO, 1992).
4. Figures supplied by WHO, Geneva, August, 1993.
5. Figures supplied by WHO, 1993.
6. Figures supplied by WHO, 1993.
7. WHO, The International Drinking Water Supply and Sanitation Decade: End of Decade Review (Geneva: WHO, 1992); and WHO and UNICEF, Water Supply and Sanitation Sector Monitor- ing Report 1993 (Geneva and New York: WHO/UNICEF Joint Monitoring Project, 1993).
8. WHO, The International Drinking Water Supply.
9. WHO, Reproductive Health: A Key to a Brighter Future. Biennial Report 1990-91 (Geneva: WHO, 1992).
10. UNICEF, The Progress of Nations 1993 (New York: UNICEF, 1993), p. 34. 11. Dilip Mahalanabis, “The Pioneering Years,” Dialogue on Diar- rhoea, No. 52 (March-May, 1993), p. 5. 12. United Nations Administrative Committee on Coordination, Sub- committee on Nutrition, Second Report on the World Nutrition Situation (New York: United Nations, 1992). 13. UNICEF, Nutrition Cluster, “A UNICEF Strategy for the Control of Iodine Deficiency Disorders,” UNICEF, May 31, 1990. 14. Ruth E. Levine etal, “Breastfeeding Saves Lives: An Estimate of Breastfeeding-Related Infant Survival,” Center to Prevent Child- hood Malnutrition (Maryland), May 31, 1990. 15. World Bank, World Development Report 1993 (Washington, D.C.: World Bank, 1993), p. 93. 16. WHO, Our Planet, Our Health (Geneva: WHO, 1992). 17. Olivia Yambi and Raphael Mlolwa, “Improving Nutrition in Tan- zania in the 1980s: The Iringa Experience,” Innocenti Occasional Papers No. 25 (Florence, Italy, March, 1992).
18. WHO, Maternal Mortality: A Global Factbook (Geneva: WHO,
1991); UNICEF, The Progress of Nations 1993, p. 39.
19. UNICEF, “World Declaration on the Survival, Protection and
Development of Children,” and “Plan of Action for Implement-
ing the World Declaration on the Survival, Protection and Devel-
opment of Children in the 1990s,” UNICEF, 1990.