11 million forgotten children
By Peggy Peck
UPI Science News
03 July, 2003
While the world's daily news headlines track the troubles in the Middle East and the latest emerging diseases -- SARS, monkey pox and West Nile virus -- nearly 11 million children are dying quietly, victims of the ancient villains: diarrhea, malaria and measles.These children die without even creating a blip on the radar of the global public health system and no film at 11.
Most of the deaths occur in south Asia and sub-Saharan Africa. In 2000, more than 2.4 million children died in India alone, and half of the estimated 10.8 million deaths of children under age 5 occurred in India, Nigeria, China, Pakistan, Democratic Republic of Congo and Ethiopia. Ninety percent of the deaths occurred in 42 countries -- 70,000 of them just south of the U.S. border in Mexico.
Duff Gillespie, who has spent the last 8 years with the U.S. Agency for International Development as the "senior career person for health," said the current crisis in childhood survival is compounded by complacency and neglect among those in a position to prevent these deaths.
Most experts agree with Gillespie's assessment.
Alfred Ironside, spokesman for the United Nations Children's Fund, told United Press International his agency spearheaded a child survival revolution in the 1970s and 1980s.
"The concept was that by investing in basic health systems we could go a long way toward reducing child mortality," Ironside explained. For example, he continued, in the early 1970s, global immune coverage, meaning vaccines for diseases such as polio and rubella, stood at only about 15 percent. So UNICEF invested in infrastructure -- installing a network of vaccine refrigerators placed at strategic locations throughout developing countries and training health workers to give immunizations. The program was so successful that by 1990 immune coverage had improved to 75 percent.
As a result of this and other UNICEF initiatives, child mortality actually declined during the '70s and '80s. However, after the immunization system was set up, "no entity was making investments to keep the human and physical infrastructure in place, to maintain the system," said Gillespie, who is now a visiting scholar at the David and Lucile Packard Foundation in Los Altos, Calif. "Each year a new batch of infants comes along and they need to be immunized. You can't neglect this for long before you find yourself really losing ground."
At the same time this not-so-benign neglect was setting in, a new health crisis consumed the international stage: HIV/AIDS.
Initially and for a variety of reasons, governments tried to ignore the disease, but as it claimed more lives, that attitude vanished and "people began to direct their energy and attention to catching up to overcome the initial neglect," Gillespie explained. However, that shift in emphasis, he said, actually undermined the child survival initiatives of the 1970s.
"Organizations aren't good at multi-tasking," he said. "It is difficult to deal with a crisis and HIV/AIDS is indeed a crisis. So a tremendous amount of time and energy and resources are focused on it."
Yet child mortality is also a crisis, and unlike HIV/AIDS, which requires heroic efforts to combat and for which there remains no cure, attacking child mortality needs only simple steps that could save perhaps 7-million children each year, according to Dr. Hans Troedsson, director of the WHO's department of child and adolescent health and development.
"That is what is so frustrating because it is not really understood by the general public or by policy makers," Troedsson said.
For example, he explained, more than 1.3 million babies could be saved if mothers relied on "exclusive breast feeding for the first six months of life, with no water or complimentary feeding." With no sanitation system, water is usually contaminated, which increases the risk for diarrhea, and diarrhea kills when babies become dehydrated. Thus teaching mothers how to rehydrate babies will save lives.
Another simple precaution: sleeping under a mosquito net treated with insecticides. It could save another 700,000 infants and toddlers because "the malaria carrying mosquitoes fly at night," Troedsson said.
This is not a widespread practice, however, because bed nets cost about $5.00 and "often we are talking about the poorest of the poor," Gillespie said. "It is not that these people don't have discretionary income, it is that they don't have income. In many areas they are still working on a barter system."
Moreover, he continued, it is not just a matter of getting bed nets into the house, but also of making sure that the "kids will be put under the nets and that it isn't a situation where the father hogs the bed net."
Another 500,000 lives could be saved each year by giving children two vaccines commonly used in the United States: Hib vaccine, which protects against Haemophilus influenzae type b bacteria that can cause both pneumonia and meningitis, and measles vaccine.
Other simple, low-tech health measures, such as giving children vitamin A and zinc supplements, improving sanitation and providing antibiotics, could save 3.5 million lives each year, said Dr. Cesar Victora of Pelotas University in Pelotas, Brazil.
Two of these interventions need not be driven by health systems, said UNICEF'S Ironside, but can be effective if they are accepted by households. "We have to figure out how to encourage exclusive breast feeding (and) how to get babies to sleep under bed nets," Ironside said.
"We also need to educate people about when they need to seek help from health care workers," said Victora. For example, he said, in many African countries when a child has convulsions caused by cerebral malaria, "it is considered a spiritual illness that should be treated by traditional healers and not health workers, who have life-saving anti-malarials available. But in Tanzania we found that if we could treat just a single child, that child's 'miraculous' recovery set an example for the whole community and soon mothers were willingly bringing their children to the health care workers."
How much would all these "simple" interventions cost? Less than might be expected, Troedsson said. He estimated $1 billion for vaccines, $2.5 billion for malaria prevention and $4 billion for basic treatment of childhood illness. For comparison, he noted, the annual bill for pet food in the United States and Europe is $17 billion.
Last spring, as concerns continued to mount in the public health community, Victora helped coordinate a conference of child survival experts at the Rockefeller Foundation's Bellagio study and conference center at Lake Como, Italy.
One of the unique aspects of that gathering, said Gillespie, was most attendees shared responsibility for the current crisis in child survival.
"There was a great deal of embarrassment, perhaps bordering on shame, that this was allowed to happen," Gillespie said. He admitted he accepts a good deal of that shame because "I was in a position of authority and at least theoretically should have been able to direct resources and establish priorities. I'm embarrassed to say that I wasn't even aware that things were going wrong until we were doing some of our regular country review sessions (and) I came across three countries in a row in which immunizations were going down. I started poking around and asked that a special analysis be done and I found that there were whole regions of the world where (immunization decline) was happening," he said.
Also during the Bellagio meeting, which was underwritten by the Bill and Melinda Gates foundation, the WHO department of child and adolescent health and development, and the Johns Hopkins family health and child survival cooperative agreement with the U.S. Agency for International Development, the experts took a hard look at the global child mortality situation. They then drafted a series of five articles that lay out the problem in stark detail, outlining the effects of interventions, and challenging world leaders to "move child survival back onto the global agenda," Gillespie said.
Beginning Friday, the British medical journal The Lancet will publish one of these articles hammered out by the Bellagio conferees each week through July 26. In addition, The Lancet is hosting a debate about the Child Survival series on its Web site and will accept contributions by e-mail addressed to [email protected].
Asked what he hoped the articles would achieve, Gillespie said he would like them used as a basis to lobby Congress as well as to attract support in the international community.
"Even in today's world this is not an unpopular topic," he said. "Every survey done in the United States indicates that saving infants' and children's lives is a worthy goal. Who could be against it? So there doesn't have to be a grassroots campaign to build support. But it has to be done in a systematic way, periodically following up to see if progress continues to be made so we don't fall into the same trap again by getting distracted and turn our attention to something else."
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