THE STRUGGLE FOR CHILDREN'S HEALTH
Adapted from UNICEF's annual report,
The State of the World's Children 1994
(Oxford University Press, 1994).
Through the lens of history, what is happening now in the developing world may come to be seen as the beginning of a final offensive against some of the oldest and most common enemies of the world's children. The most important aspect of this progress 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 immunization, measles cases have been reduced to approximately 25 million a year and deaths from the disease have been cut to just over one million.
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, approximately four million children a year were dying from diarrheal disease. But since 1985, the technique of oral rehydration therapy (ORT) has been put at the disposal of approximately 250 million families or about one third of the developing world's children. Sixty countries now produce packets of oral rehydration salts (ORS) according to the formula developed by the World Health Organization (WHO) and UNICEF, and more than two thirds of the world's population can obtain ORS within a reasonable distance from their homes. The result is the prevention of more than a million deaths a year from diarrheal disease.
The 1980s and early 1990s have also seen the raising of immunization levels from under 20 percent to approximately 80 percent-- undoubtedly one of the greatest public-health achievements of this or any other century. In addition to its contribution to measles control, immunization has also made major inroads into territories 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. 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.
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. 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 illnesses 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 disease; 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 represent a significant gain against the fundamental problems of malnutrition, and poor mental and physical development.
Recent years have also seen steady progress in extending safe water and sanitation to millions of families in the developing world. Since 1980, the proportion of families with access to safe drinking water has risen from 38 percent to 68 percent in Southeast Asia, from 66 percent to 78 percent in Latin America, and from 32 percent to 43 percent in Africa. Safe sanitation has advanced more slowly, but more than half of all families in the developing world can now dispose of feces safely. 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 planning. 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 proportion of married women using modern methods of family planning has increased from less than 10 percent to approximately 50 percent. The speed of this change is unprecedented in demographic history, with some 17 nations succeeding in halving their fertility rates in only one generation.
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 significant contributions to human well-being of recent years.
Advances 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-deficiency disorders in Switzerland and the United States during the 1920s.
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, infra-structure and communications capacity in most developing nations have now reached the point at which it is physically and financially possible to bring the basic benefits of scientific 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 levels of immunization coverage in the developing world indicate that a system is now in place--including a capacity for training, supply, management, communications, delivery, and record-keeping- -that is capable of reaching out to over 100 million infants a year on four or five separate occa-sions during their first year of life. That outreach system, extending to almost every rural hamlet and urban neighborhood, is very far from being uni-versally 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 worldwide public and political awareness that such advances are now possible, that both the scientific knowledge and the outreach capacity are now available, and that 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.
This awareness has begun to translate itself into political pressures. An early example was the commitment to the 80 percent immunization goal made by almost all national political leaders in the mid--1980s. At that time, only a third of the developing world's children were being immunized; just over five years later, close to 80 percent were being protected by vaccines.
At about the same time as the immunization goal was being 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 outrage that something as simple, preventable, and treatable 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 percent 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 developing 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? Why was iodine deficiency still the leading cause of preventable mental 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 children, when the problem could be prevented by something as affordable and manageable as iodizing all salt supplies? 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? And why were nearly a million people still suffering the painful and debilitating effects of guinea-worm dis-ease when the cost of control in affected areas had been reduced to only about $2.50 per person?
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? 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? Why do surveys show that one pregnancy in five in the developing world is unwanted when today's communications and out-reach 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 l-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?
In 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 economic affairs. The World Summit for Children, held at the United Nations in New York, was attended by representatives of almost every nation, including 71 presidents 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 reductions 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.
Briefly, those new goals include a one-third reduction in under-five mortality rates, the halving of child malnutrition, the achievement of 90 percent 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 percent 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 children from the worst effects of poverty. And it is a price which could be easily afforded if even 20 percent of present government spending in the developing world, and 20 percent 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 percent of government spending and of overseas 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 developing world's governments have also agreed to 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 percent reduction in measles deaths, the promotion of ORT to 80 percent 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 percent immunization levels in all countries that have not yet reached that goal.
Sidebar:
The Rights of Children Under UNICEF
The Convention on the Rights of the Child was adopted by the General Assembly of the United Nations on November 20, 1989. It has now been ratified by 159 countries, including every country in the Americas except for the United States. It establishes for the first time in an international convention that children are citizens with certain definable rights, and that those rights, in the main part, consist of particular protections from their respective governments. That many of the rights listed below had to be specified, is an indication not only of the powerlessness of childhood, but of the daily horrors that many of the world's children find themselves subjected to. Among the rights agreed to by the parties to the Convention are the following:
In addition to respecting these rights, governments which are party to the Convention agree to certain responsibilities, among them: the provision of appropriate assistance to parents in child raising; the protection of children from maltreatment by parents or other caretakers; and the provision of alternative family care or institutional placement for children deprived of a family environment.