The Struggle for Children's Health This article is adapted from UNlCEF'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.2 The result is the prevention of more than a million deaths a year from diarrheal disease.3 The 1980s and early 1990s have also seen the raising of immunization levels from under 20% to approximately 80%_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 400,000.4 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 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 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 rep resent 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% to 68% in South-East Asia, from 66% to 78% in Latin America, and from 32% to 43% in Africa.7 Safe sanitation has advanced more slowly, but more than half of all families in the developing world can now dispose 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 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% to approximately 50%.9 The speed of this change is unprecedented in demographic 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 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.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 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 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 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% 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% 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% 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. Part 2 of 3 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? 12 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? 13 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? 14 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? l5 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? 16 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? 17 Why do surveys show that one pregnancy 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 l-in-20 risk of dying in childbirth when the risk for a woman in the industrialized world had been reduced to about l in 3,600? 13 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.'9 Briefly, those new goals include a one-third reduction in under-five mortality rates, the halving of child 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 children from the worst effects of poverty. And it is a 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 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% 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% immunization levels in all countries that have not yet reached that goal. R The Rights of Children 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: ? The inherent right to life. ? The right to a name at birth. ? The right to express his or her opinion freely, and have that opinion taken into account in any matter affecting the child. ? The right to meet with others and to join or form associations. ? The right to the highest standard of health and medical care attainable. ? The right to enter or leave any country for purposes of maintaining the parent-child relationship. ? The right to primary and secondary education. ? The right to be protected from work that threatens his or her health, education or development. ? The right to be protected from sexual exploitation and abuse, including prostitution and involvement in pornography. ? The right to be protected from torture, cruel treatment or punishment, unlawful arrest or deprivation of liberty. (Capital punishment and imprisonment without possibility of release are prohibited for children under the age of 18.) ? The right to be protected from recruitment into the armed forces below the age of 15. 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. Part 3 of 3 TABLE 1 Infant/Maternal Health: Selected Countries DPT is diphtheria, pertussis (whooping cough) and tetanus. ORT use rate is the percentage 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. Contraceptive prevalence is the percentage of married women aged 15-49 currently using contraception. % Fully Immunized ORT Use Maternal Contraceptive COUNTRY DPT Polio Measles Rate Mortality Prevalence Brazil 69 62 93 63 200 66 Chile 91 91 90 10 67 43 Colombia 77 84 74 40 200 66 Cuba 91 93 98 80 39 70 Mexico 91 92 91 63 110 53 Nicaragua 73 86 72 40 NR 27 Peru 80 81 80 31 300 59 Canada 85 70 85 NR 5 73 USA 58 74 77 NR 8 74 Source: UNICEF, The State of the Wor/d's Children 1994 (New York: Oxford University Press, 1994) TABLE 2 Malnutrition Indicators: Selected Countries Infant and under-five mortality rates are the number of deaths per 1,000 live births under the ages of one and five years respectively. Low birthweight is the percentage of children born weighing less than 2,500 grams (5.5 Ibs.). Goiter rate is the percentage of children with goiter, an indicator of iodine deficiency which causes brain damaqe and mental retardation. Infant Under-five Low Goiter Rate COUNTRY Mortality Mortality Birthweight (6-11 years) Brazil 54 65 11 14 Chile 15 18 7 9 Colombia 17 20 10 10 Cuba 10 11 8 10 Mexico 28 33 12 15 Nicaragua 54 76 15 4 Peru 46 65 11 36 Canada 7 8 6 NR USA 9 10 7 NR Source: UNICEF, The State of the WoHd's Children 1994 (New York: Oxford University Press, 1994). TABLE 3 Access to Services: Selected Countries All numbers are percentages of the Population. Access to Access to Access to SAFE WATER SANITATION HEALTH SERVICES COUNTRY Urban Rural Urban Rural Urban Rural Brazil 95 61 84 32 NR NR Chile 100 NR 100 20 NR NR Colombia 87 82 84 18 NR NR Cuba 100 91 100 68 99 96 Mexico 81 68 70 17 80 60 Nicaragua 76 21 78 NR 100 60 Peru 77 10 77 20 NR NR Source: UNICEF, The State of the World's Children 1994 (New York: Oxford University Press, 1994). INSERT The Precarious Situation of Latin America's Children The most visible tragedy in Latin American cities has been the appearance of millions of street children. Like the tip of an iceberg, the appearance of the street children represents a tragedy of much greater proportions. Beneath the street children phenomenon lies a mass of less visible suffering, characterized by the stunted lives of child workers, the terror of child prostitution, and the poverty of indigenous children and children in peasant communities. The street children remind us that while poverty remains most acute in rural areas, the rapid urbanization of Latin America has made poverty_ most visibly_an urban phenomenon. Seventy percent of the Latin American population and 57% of the poor now live in urban areas. These figures sharply contrast with the world's other developing regions where the majority of children live in rural areas. In 1985, for example, 64% of Latin American children under the age of 15 lived in cities, as opposed to only 29% of the African population of the same age. It is in cities that the relative deprivation of living standards and social rights is most acute. The difficult conditions borne by millions of Latin American children_and their families_were particularly sharpened during the "Lost decade" of the 1980s. The precarious situation in which the majority of Latin American children are growing up has been further aggravated by the policies of economic adjustment adopted by most governments in response to the debt crisis, the major economic problem of the 1980s. Adjustment policies often produced a reduction of employment and wages, rising prices of basic goods (especially food), and reduction of public spending on public and social services. As a result of the economic crisis and the policies of adjustment, the percentage of families living in extreme poverty rose dramatically during the first half of the 1980s: from 12% to 16% in Santiago de Chile for example, and from 17.3% to 29.4% in San Jose, Costa Rica. Studies show that impoverishment has hit families with the most children the hardest. Reduced spending on social services and falling family incomes have a negative impact on the quality of care that can be offered to children in extreme poverty. As a consequence, infant mortality continues to be a problem in the region. For every thousand live births, 50 children die before their fifth birthday. This rate is six times higher than in the United States and Canada. In Haiti and Bolivia, the under-five mortality rate has reached alarming levels, 133 and 118 respectively. Easily prevented diseases like diarrhea and respiratory infections, along with malnutrition, are the principal causes of these childhood deaths. It is estimated that four million children under five die each year from diarrhea. The sudden reappearance of cholera, an epidemic thought to be eradicated a century ago, constitutes dramatic evidence of the precarious conditions of health among a large part of the Latin American population. The reduction of income reinforced the necessity of child labor, frequently in unhealthy conditions, in order to support family subsistence. It is an error to suppose, in this context, that the child of the street has been "spontaneously generated" and lacks any family. In the majority of cases, these children form a part of a "family of the street" providing mutual aid to one another. Into this bleak landscape, some hope has been introduced in the form of the World Convention of Children's Rights. The years leading up to the World Convention were characterized in Latin America by profound economic and political crises. Most of the countries in the region had deeply authoritarian governments, typically installed by military coups. In this sense, the arrival of the decade of the 1980s, while it sharpened the economic crisis, signaled at the same time a democratic political opening. This democratic opening represents a special condition for Latin America, and the great challenge of the 1990s is to maintain it. In this context, the living conditions of the great masses of the urban and rural poor, especially young people, will have a determinate influence on the consolidation of the democratic system. The problems of our children are important for their own sake, but in addition, their solution is imperative for the future of a democratic system which can't exclude them if it is to survive. _Eugenia Maria Zamora Chavarria Eugenia Maria Zamora Chavarria is the director of the Instituto Interamericano del Ni#o in Montevideo, Uruguay. Translated from the Spanish by NACLA. REFERENCIAS 1. United Nations Children's Fund (UNICEF), The State of the World's Children 1993 (New York: UNICEF, 1993), p. 5. 2. Dialogue on Diarrhea, No. 52 (March-May, 1993). 3. World Health Organization (WHO), Programme for Control of Diarrheal Diseases, Interim Programme Report 1992 (Geneva Switzerland: WHO, 1992). 4. Figures supplied by WHO, Geneva, August, 1993. S. 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 Monitoring 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 Diarrhea, No. 52 (March-May, 1993), p. S. 12. United Nations Administrative Committee on Coordination Subcommittee 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, "Breast feeding Saves Lives: An Estimate of Breast feeding-Related Infant Survival," Center to Prevent Childhood Malnutrition (Maryland), May 31, 1990. 15. World Bank, World Development Report 1993 (Washington, DC: World Bank, 1993), p. 93. 16. WHO, Our Planet Our Health (Geneva: WHO, 1992). 17. Olivia Yambi and Raphael Mlolwa, "Improving Nutrition in Tanzania in the 1980s: The Iringa Experience, " Innocent Occasional Papers No. 25 (Florence, Italy, March, 1992).