The Progress of Nations: Health

Commentary: Unfinished business

By Monica Sharma and James Tulloch

Children in rich countries do not die from the common, preventable diseases of childhood. Children in poor countries do.

Except in rare and isolated cases, measles, diarrhoea, malaria, pneumonia, and malnutrition no longer claim the lives of children in the industrialized world. But in poor countries, these five conditions kill more than 8 million children a year - and account for two thirds of all under-five deaths.

As the 20th century draws to an end, it is or ought to be a source of profound international shame that over 8 million children are allowed to die each year from problems that have long ago been overcome in other parts of the world. A famine that kills 10,000, an earthquake that kills 1,000, a plane crash that kills 100 - all of these may stir the world to pity and protest. But the deaths of almost 25,000 children every day from five causes for which we long ago discovered inexpensive means of prevention or cure are allowed to pass with barely a murmur. It is as though a cure for heart disease or cancer or AIDS had been discovered but not used. And if the comparison seems far-fetched, let it be remembered that diarrhoeal disease claims half as many lives as heart disease, respiratory infections more lives than cancer, measles more lives than AIDS. And the victims of these preventable conditions are, in the main, children under the age of five.

The extraordinary lack of protest can be put down to two principal factors. The first is that these 8 million deaths do not happen in a particular place at a particular time. They do not, therefore, meet the criteria of the news media. Second, they are almost always the deaths of children from the least-regarded families in the world, families on the margins of life, families without political influence, without economic power, without media access.

Progress

If the tragedy of preventable child deaths has passed largely unrecognized, then so too has the progress that has been made in recent years.

Over the last decade and a half, UNICEF and WHO have led a worldwide effort, working with governments and non-governmental organizations (NGOs) all over the world, to begin reducing the toll of the ordinary diseases of childhood.


Photo (above): It is as if cures had been found for heart disease, cancer and AIDS - but not put into effect.©


In that time, immunization has been extended from about 25% to almost 80% of the developing world's children, preventing more than 3 million deaths a year from diphtheria, measles, whooping cough, and tetanus. By the same means, polio cases have been cut from approximately 400,000 a year to just under 100,000. Also since 1980, the technique known as oral rehydration therapy (ORT) has been put at the disposal of most poor communities, averting approximately 1 million deaths a year from diarrhoeal dehydration. More recently, a sustained advance has also been made against the vitamin A deficiency which renders common diseases more likely to be fatal and is associated with between 1 and 3 million child deaths each year.

This effort has not been directed only at saving lives. Prevention and proper treatment of common illnesses also help to protect the growth and normal development of far larger numbers of children (see Nutrition section). In particular, the campaign to iodize salt and so eliminate iodine deficiency disorders, long the world's biggest cause of preventable mental retardation, is now close to success in 30 nations.

In sum, the progress made in one generation means that as many as 5 million fewer children each year are dying, and that at least three quarters of a million fewer are being disabled, blinded, crippled, or mentally retarded.

Although little noticed in the industrialized nations, this advance must be ranked as one of the great achievements of the second half of the 20th century.

A job half done

In an attempt to maintain this momentum, the 1990 World Summit for Children brought together a majority of the world's presidents and prime ministers to discuss current opportunities for further reducing the toll of ordinary childhood illnesses. The result was agreement on a set of basic goals to be achieved by the year 2000. Progress so far is summarized in The immunization record.

Around this consensus on what could and should be done, United Nations agencies are working with governments and NGOs to put known solutions into practice on the necessary scale. UNICEF has dedicated most of its efforts and its advocacy to this cause for the last 15 years. WHO has provided the scientific guidance and helped to train over a million health workers in the proper management of the common and preventable diseases of childhood. Both organizations have devoted themselves to the planning, implementation, and evaluation of well-defined priority health interventions.

But despite the progress made, the job of preventing ordinary illnesses from killing, disabling, and malnourishing so many millions of children is less than half done. And over the next decade, the priority must be to finish what has been started. Recent years have shown that, with some support from the international community, almost all governments can now command the knowledge, the technology, and the outreach capacity to enable most families to protect the lives and the normal growth of their children. If there was little excuse for the deaths of millions caused by ordinary diseases in 1980, there is none at all now.

As in so many other arenas of the possible, the weak link is still the relatively low level of political commitment, in many countries, to doing what can now be done.

The other main danger is a complacency born of two common misunderstandings.

First, the dramatic increase in immunization is not a once-and-for-all achievement but an effort that must be renewed with each generation of infants. Over 120 million babies are born into the developing world each year, and all of them need to be vaccinated on four or five occasions during the first year of life.

Second, there is a widespread if unspoken belief that reaching 40% or 50% with ORT and 70% or 80% with immunization is good enough. But the fact is that frequent illness, poor growth, and early death are concentrated among the poorest - the minorities, the geographically remote, the despised, and the discriminated against.

In other words, they are concentrated among those who have not yet been reached.

Finishing the job, reaching the unreached, and ending the shameful toll of the ordinary diseases of childhood, must therefore continue to be a priority in the remaining years of the 1990s.

At the same time, a continued effort is required to strengthen the basis for sustained progress in improving health - through guaranteeing basic health services, adequate nutrition, safe water and sanitation, and family planning services, to all communities.

Focus on the child

Targeting individual diseases can take us only so far down the road towards the goal of controlling the ordinary illnesses of childhood.

For the foreseeable future, hundreds of millions of children will continue to fall ill and will continue to be brought to clinics and health centres throughout the developing world. And it is how those clinics and health workers respond that will largely determine whether childhood illnesses will continue to decimate poor communities.

At the moment, the majority of health centres are failing those children. Many die from preventable or treatable diseases even after they have been brought to clinics. And many parents leave without essential drugs and advice on how to prevent or treat the conditions that threaten the life and normal growth of their children. At all levels of primary care, health workers are too often badly trained, poorly supervised, underpaid, or absent from their posts. Parents with sick children may have to queue for hours, only to receive peremptory treatment, or be told that the drug cupboard is bare. Often, also, there is no working system of referral for those cases where more qualified care is needed.

It may be that this state of affairs is the result of cuts in government spending, perhaps as a result of economic adjustment programmes. Or it may be that 80% of the health budget is being spent on one or two big city hospitals serving only a minority of the population. But whatever the cause, the result is that many families in the developing world are abandoning public health services in favour of private practitioners who, in many cases, offer them not the most appropriate treatment but the most expensive. So is lost an opportunity for making available today's effective and inexpensive treatments - and for the provision of vital information and advice.

Without an improved response from health workers and health clinics throughout the poor world, it will not be possible to finish the job and bring the ordinary diseases of childhood under control. What can be done?

It might be imagined that the millions of children brought to clinics and health centres are suffering from a wide variety of different health problems and that a competent response therefore requires many years of medical training. But the fact is that about 80% of all such children are suffering from one or more of the five common conditions - diarrhoea, measles, respiratory infections, malaria, or malnutrition - for which the treatment is relatively inexpensive and the advice needed by parents is relatively straightforward.

The complication is that, in practice, the child will usually display symptoms reflecting more than one of the most common health problems. The response must therefore be based on an assessment of the individual child; and a competent health worker must be capable of dealing simultaneously with more than one health problem.

In addition to the continuing effort to prevent disease and to enable families themselves to protect their children's health, the great challenge of the years immediately ahead is the challenge of ensuring that any family taking a child to a clinic or health centre anywhere in the developing world will find a health worker who can examine and diagnose, make a decision on appropriate treatment, give basic drugs for the most common problems, refer the child to hospital if needed, and offer the right advice about how best to prevent and manage illness in the home.

Daunting as it may sound, this challenge can be met. In the 1990s, WHO and UNICEF have drawn up step-by-step guidelines to enable front-line health workers to deal competently with all of the ordinary diseases of childhood. Those guidelines have now been successfully field tested by WHO and UNICEF in several countries. To train or retrain a health worker to work within those guidelines requires just 11 intensive days of individual and group work in the classroom and hands-on, supervised practice. It is therefore far from being an impossible task.

With 14 basic drugs at their disposal, and with higher-level health services to refer to if necessary, these trained, first-level health workers can respond adequately to the needs of more than 80% of the children who are brought to clinics and health centres.

Essential drugs

The preparation and the trials are behind us. The task ahead is one of putting the training programmes into practice and ensuring that the skills, support, and supervision are in place on the necessary scale.

It is at this point that the question of resources usually arises. For it is assumed that action on such a massive scale cannot be afforded - that training and supporting enough health workers, and equipping them with enough drugs, is simply too expensive for the governments of poor countries. But even the crudest of calculations can lay this myth to rest.


Photo (below): A health worker requires just 11 days of intensive training to be able to deal competently with the ordinary diseases of childhood.©


According to WHO, it would probably require, for example, training as many as 850,000 health workers. The cost of that might be approximately $200 million. To put that figure in perspective, it is about 0.2% of the amount that the developing world's governments are already spending on health services.

Nor do the drugs required pose any insuperable financial hurdle. WHO and UNICEF have drawn up a list of the essential drugs required to deal with most of the common diseases of childhood. They include oral antibiotics for pneumonia, dysentery, and ear infections; an oral antimalarial drug; paracetamol for fever; oral rehydration salts for diarrhoeal dehydration; vitamin A for children with measles or vitamin A deficiency; mebendazole for intestinal parasites; tetracycline ointment for eye infections; and gentian violet for mouth ulcers and bacterial skin infections. The average cost for a full course of these treatments is approximately 15 cents. So even if every single child under five in the developing world had to be given a course of drugs twice a year every year, the total cost would still be considerably less than $200 million per annum.

Even when we combine the costs of both training and treatment, and even if we assume that the training component would be an annual cost (to allow for retraining and supervision), then the total bill still amounts to less than half of 1% of the amount that the governments of the developing world are already spending on health services each year.

Much more than finance is needed. In particular, it will require a major political commitment and a significant degree of reorientation of higher-level health services to provide the essential referral and supervision services. Given that commitment, the technologies and the training methods are now available and affordable, and in most countries the outreach and communications capacity are already in place.

Controlling the ordinary diseases of childhood is therefore technically and financially feasible. The idea that national governments and the international community do not have the resources is not to be taken seriously. Within a decade, any clinic or health centre worthy of the name should be providing basic, competent treatment for all of the most common health problems of childhood. That is now the right of all children - and the responsibility of all governments.


Dr. Monica Sharma is Senior Adviser for Child Health at UNICEF headquarters in New York. Dr. James Tulloch is the Director of the Division of Child Health and Development at WHO headquarters in Geneva. Both have worked in international public health for the last 20 years, and both have been responsible for assisting countries to control diarrhoeal diseases and acute respiratory infections which, taken together, account for over half of all child deaths in the developing world.

This article was written in collaboration with Peter Adamson.


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