Global Health & Environment
spring/summer 1997, Vol. 5, Issue 1
Child Survival Deserves Global Action
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Center for Communications, Health, and the Environment
A Future Within Reach
by Ronald Waldman, MD, MPH, Lyndon Brown, MPH, and Marcia Rock, MPH, BASICS, Arlington, Virginia
Each year, more than 12 million children die before reaching the age of five. This statistic is an improvement over the situation, which existed in years past. In India, for example, deaths among children under five have fallen from 236 to 115 per 1000 live births since 1960.
In Central and Eastern Europe and republics of the former Soviet Union, rates of child mortality range widely: While the Czech Republic compares favorably with the United States (both with approximately 10 deaths per 1000), and Slovenia with the Netherlands (both with 8 deaths per 1000),the childhood death rates of the newly independent countries of the Caucasus and Central Asia are similar to those in some developing countries. Armenia and Thailand, for example, report ratios of 32and 31 deaths per 1000 live births, respectively, and Turkmenistan, with the highest child mortality rate of 85 per 1000 in the region, exceeds that of Namibia (78), Indonesia (75) and Guatemala (67), among others.
Global Call to Action
Yet a bold move to improve child survival was first conceived in Soviet Central Asia. In September 1978, officials from 134 countries gathered in the city of Alma-Ata. Convened by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), they had come to develop Health for all - strategy based on the notion of primary health care to guide public health efforts through the end of the century.
For some, the concept of primary health care seemed more visionary than strategic: attractive in principle, but difficult to implement. The essential elements for its success - a multi-sectoral approach with active involvement of the community and wide dissemination of appropriate technology - we reconsidered beyond the political will and economic resources of many countries at that time.
"Selective primary health care" was therefore proposed as a feasible, near-term alternative, with the emphasis on reducing those diseases of childhood that cause the greatest burden of disability and death. Then came the 1982 World Bank declaration that global infant and child mortality could be reduced by half with simple, low-cost means of prevention and treatment. In the same year, UNICEF called fore world-wide child survival revolution, and intervention programs proliferated.
The major causes of childhood disability and death in developing countries are infectious diseases, diarrhea and malnutrition. These were among the first conditions addressed by child survival programs, which also addressed tuberculosis, diptheria, whooping cough, polio, tetanus and measles. An important medical breakthrough, the development of inexpensive and easy to use oral rehydration salts (ORS), made it possible to launch a major effort to reduce mortality from diarrhea diseases, at that time, the leading cause of death among children in the world. Programs promoting twin engines of child survival - immunization and ORS, were implemented in all developing countries, and childhood mortality, instead of increasing because of soaring birth rates, the spread of AIDS and growing resistance of bacteria to antibiotics, was reduced by about one-third during the 1980s and early1990s. Nutrition programs further contributed to mortality reduction through expanded growth monitoring and promotion of exclusive breast-feeding for the first six months of life, and the use of vitamin A supplementation in areas with high childhood mortality. Finally, programs with improved diagnosis and treatment of acute respiratory infections, including pneumonia, which had by the early part of this decade replaced diarrhea as the leading cause of death, rounded out the content of child survival programs.
Throughout this period, in the Soviet Union and other countries of Eastern and Central Europe, the principal illnesses of children were kept in relative check. Vaccination coverage rates were high, and children with potentially life-threatening diarrhea and pneumonia were either hospitalized (often unnecessarily) or given close attention at home by a health care professional. Although the recommendations of the WHO were not consistently heeded (for example, the vaccination schedule varied considerably from that used in most of the world), the highly centralized system ensured nearly universal access to health care for the entire population.
The relatively adequate provision of primary care, however, was not matched by appropriate strategies to address other components of the region's health, such as environment, lifestyle and nutrition and these worsened considerably. Smoking and excess alcohol, and the traditional regional diet, laden with cholesterol-rich foods, sugar, salt, and alcohol, and practically devoid of plant foods continue to take a severe toll among adults and indirectly among children too, in all countries of the region. Approximately 17 percent of the former USSR has been declared an ecological crisis area, the Czech and Slovak Republics have the highest levels of toxic emissions per capita in the world; and large parts of Poland, Hungary and Bulgaria have extreme levels of air, water and soil pollution with increased rates of respiratory disease and certain types of cancer.
The dissolution of the Soviet Union, however, has meant that its former member countries, especially republics of the Caucasus and Central Asia, have been unable to replace the crucial Soviet support with sufficient resources for vaccines and other essential health commodities. The skills and technology needed to manage a health care system efficiently and effectively are also lacking.
During the early 1990s, with immunization coverage declining, a number of previously controlled infectious diseases began to re-emerge: A severe diphtheria epidemic spread through all 15 of the former Soviet republics, with a total of nearly 150,000 cases and 4000 deaths as of December 1996. And major polio outbreaks have occurred in Uzbekistan (1994) Chechnya (1995) and most recently, Albania (1996).
Furthermore, children's nutritional status is deteriorating. Diarrhea and pneumonia are once again among the leading causes of childhood deaths. And, tragically, childhood mortality rates appear, at least in some countries, to be increasing.
Investing in the Future
International concern for the well being of children prompted humanitarian assistance efforts from early 1992,especially for the Caucasus and Central Asia, and Moldova. Airlifts delivered essential equipment, vaccine and medical supplies provided by the United States, Japan, EU and other donors.
In addition, and more importantly, for the long-term, international agencies (UNICEF, WHO, USAID and others) began to provide technical assistance to Ministries of Health, introducing more efficient planning and management tools, and supporting the development of national programs to address priority child health problems. The same interventions that had proved so effective elsewhere were now seen to be adaptable and vitally needed to improve child survival in these countries.
Over the past five years, mass campaigns have been conducted throughout the region to immunize all age groups against diphtheria, and its incidence has declined almost as abruptly as it rose. National immunization days for polio eradication have been conducted in the Caucasus and Central Asia each spring since 1995, and more recently in Russia as well, with very few cases now being reported in the region. Programs for the control of diarrhea! disease and acute respiratory infections, as well as promotion of breast-feeding and better child nutrition, have been established in eight countries, and these too show promising results.
Demographic Changes Portend Troublesome Trends in Central and Eastern Europe
Jana Parizkova, MD, PhD, D.Sc, Charles University, Prague, Czech Republic
In the last decade, countries in Central and Eastern Europe have witnessed major political, economic, socio-cultural and environmental turmoil - changes that have directly and indirectly affected the health and survival of our society, especially of our children and youth. While rheumatic fever, tuberculosis, non-specific lung and respiratory diseases, infections and ailments of the genitourinary tract have been on the decline in most countries of the region, others such as allergies, congenital anomalies, coronary heart disease, diabetes, skin diseases and chronic conditions have increased, even among children and adolescents.
The Czech Republic - A Case in Point
Take the Czech Republic, for example. This country of relatively stable economic, social and political conditions presents a relatively favorable picture. It has seen the greatest decrease in mortality of all post-communist countries. In the last 10 years, neonatal mortality decreased by between one-fourth and two-thirds from 1979 to1995. Infant mortality decreased from 20.2 per l000 live births in 1979 to 10.0 per 1000 live births in 1989 and further to7.7in 1995. About half of all infant deaths were caused by conditions originating in the perinatal period, one-quarter by congenital anomalies and some 5 percent by external causes. Mortality in children under five years of age has decreased by one-half from 1970 and by one-fifth from 1989 to 1995. In common with many European countries, the proportion of children under 14 years of age has decreased from 18.9 percent to 18.3percent in the Czech Republic while the proportion of persons over 60 has remained constant (18 percent) - indicating low birth rate and high mortality in the upper age groups.
For the second time since 1918, the number of deaths exceeded the number of births, thus attaining a negative population growth rate of 2.1 per 1000 inhabitants. Life expectancy has only slightly increased since the beginning of the 1990s to 69.5 years for males and 76.5 years for females- higher than most countries in the region, but well below the average in Western Europe, North America and Japan.
The outlook, however, has not been as hopeful for children in other countries in Central and Eastern Europe. Poverty among children has risen faster than in any other group because of the rapid spread of unemployment and low-paying jobs together with proportionally smaller allowances for children. As a result, lower real incomes and less favorable relative prices have generally exacerbated dietary imbalances typical in Central and Eastern Europe. There has been a shift in dietary composition to less expensive and more filling foods, such as those with excessive fat, which contributes to obesity and other chronic conditions. The most frequent causes of death in the adult population, for example, are diseases of the cardiovascular system and neoplasms.
In children, congenital malformations increased by one-fourth between 1984 and1995 in the Czech Republic. In certain other countries such as Russia and Romania, deterioration of the diet, hygiene, and sanitary and housing conditions have caused an increase in diseases traditionally associated with poverty.
The high proportion of chronic diseases in the region beginning in early childhood points to lifestyle as the key culprit. Inadequate diet, little physical activity and high exposure to environmental hazards are common throughout the region. However, because chronic diseases manifest themselves gradually, the short-term impact of poor lifestyle may be difficult to quantify. The long-term health consequences of poor lifestyle premature onset of chronic noncommunicable diseases - in contrast are well established and likely to be severe. And, in the absence of adequate intervention to prevent premature onset of chronic diseases, the children's future may be in jeopardy.
An increase in the incidence of low birth weight babies also points to deteriorating nutritional status in most countries in the region. Death rates for infants and children have increased mostly due to perinatal causes and infectious diseases in countries where vaccination coverage has dropped, while the rise of mortality in youth, highest in Hungary and the Czech Republic, can be attributed to accidents, poisonings, violence and suicide.
Prevention - Now
As UNICEF notes in its report "Crisis in Mortality, Health and Nutrition" (1994), these unfavourable trends, partly dictated by budgetary restrictions, have created a shortage of financial and material resources, and jeopardized preventive health services which threaten the very process of reform in the region.
The health of our children is the key to the health of our region. Rectification of lifestyle, especially diet and physical activity, are key to reducing risks of non-communicable illnesses such as cardiovascular disease, metabolic disorders, diabetes and obesity in children. The old adage, "Prevention is better than cure" applies.
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