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.
