Children around the world face many threats to their health, from direct causes such as malnutrition, infectious diseases, or the lack of healthcare resources, as well as from more indirect, underlying factors, such as poverty, politics, and culturally determined behaviors and beliefs. Most of the burden of death and serious disease falls upon the children who live in developing countries. This article examines the most important causes of childhood death, the leading risk factors and social problems affecting the health of children, and efforts designed to reduce death and disease among children using the scarce resources available.
Best estimates are that about 1 1 million children younger than 5 die each year, almost all in developing countries. The vast majority of these children are lost to preventable and curable illnesses such as diarrhea and respiratory infections. Inadequate nutrition is at the root of more than half of these deaths (Figure, see page 649). The youngest children are the most vulnerable, with about one-third of deaths before age 5 occurring in the first month of life.1
Death rates of infants and children vary considerably among countries and between the wealthy and the poor within a given country. Unfortunately, these gaps are widening. In 2000, the mortality rate of children in sub-Saharan Africa was 29 times higher than that in industrialized countries.2 By one recent estimate, half of all child deaths occur in just six countries - India, Nigeria, China, Pakistan, the Democratic Republic of Congo, and Ethiopia - and 90% of deaths occur in just 42 countries.3
Acute Respiratory Infection
Acute respiratory infection is the most common cause of death in children worldwide. Pneumonia and other acute respiratory illnesses continue to kill about 2 million children each year. Most of these deaths occur in the developing world, where they are caused primarily by the same bacterial and viral pathogens found in pediatricians' offices across the United States and Europe. The difference is that the children who die are usually underweight, often with micronutrient deficiencies, and have fewer treatment and prevention options.
Relatively simple approaches could do much to prevent these deaths. For example, vaccines such as those available for Haemophilus influenzae type b and Streptococcus pneumoniae could prevent many of these deaths, but they are still considered too expensive to give to many of the world's poor children. Likewise, wider use of basic antibiotics could do much to save children. A recent meta-analysis suggested that wider, appropriate antibiotic use could reduce mortality from pneumonia by about 42%, 36%, and 36% in neonates, infants, and children up to age 4, respectively.4 Because malnutrition is such a strong contributing factor, eliminating childhood underweight alone probably could reduce all deaths from acute respiratory infection by more than half.
Diarrheal diseases remain the second-leading specific cause of mortality in children worldwide and claim approximately 1.6 to 2.5 million children each year, nearly all in developing countries.5 Again, the pathogens involved are largely the same as in developed countries, but the proportions are somewhat different. As in developed countries, rotavirus is the single most important pathogen, but bacterial etiologies combined cause more cases of acute diarrhea. Bacteria such as enterotoxigenic Escherichia coli (ETEC) are more common in areas of poor hygiene and sanitation. Shigellae and ETEC cause significant morbidity and mortality, followed by cholera, whereas Salmonelle are not a significant cause of diarrhea (but cause typhoid fever). Campylobacter infections are also common and often acquired from free-running chickens near houses.
Malnutrition also is linked closely to repeated episodes of diarrhea. Children frequently enter a downward spiral of diarrhea exacerbating malnutrition and malnutrition leading to more episodes of diarrhea. It is estimated that, of all deaths in children due to diarrhea, malnutrition was an underlying cause in approximately 60%.2 Vitamin A deficiency and zinc deficiency, both common in developing countries, also significantly increase the risk of death due to diarrhea. (See also the article by Dr. Neumann et al. on page 658.)
Most diarrheal deaths in children could be avoided by relatively simple methods such as increased breastfeeding, healthier weaning practices, and better household sanitation and hygiene. For example, hand-washing with soap has been estimated to reduce the risk of diarrhea by more than 40% and might save more than 1 million lives annually.6 Other practices that can decrease diarrheal mortality include improved female education (better home management of diarrhea and early care seeking), measles immunization, continued feeding during diarrheal attacks, provision of vitamin A, and rational use of drugs.
The use of oral rehydration solutions (ORS) to prevent and treat dehydration, often called one of the most important medical advances of me 20th century, has saved the lives of millions of children since its introduction in 1979. Especially between 1990 and 1995, dramatic improvement took place in the home management of diarrhea using ORS, and an estimated 1 million lives were saved annually. In 1990, ORS was used in only about one-third of diarrhea cases, but by 1995, the average use was in 85% of cases among 33 reporting countries that account for about half of the world's population younger than 5.7 The overall ORS use rate for cases of diarrhea in developing countries is now up to about 70%.8
Malaria is present in about 100 countries, but most deaths occur in Africa, where efficient Anopheles mosquito vectors transmit the most pathogenic of the four human malaria parasites, Plasmodiun falciparum. Each year, I to 2 million children die from malaria, and hundreds of millions become ill. Progress against malaria has been hampered by many factors, including mosquitoes that have become resistant to insecticides, malaria parasites that have become resistant to drugs, insufficient supplies of effective drugs, and lack of success in developing safe and effective vaccines.
Globally, malaria control efforts are currently focusing on the use of insecticide-treated bed nets, improved case management, and intelligence-based interventions. The treated nets work by reducing the number of bites and by killing high-risk, household-feeding mosquitoes. Improved case management efforts rely on attempting to make available affordable but effective drugs. Drug resistance is driving the increasing use of artemisinin-class combination drugs. Epidemic control is relying on geographic information systems combined with intelligence (eg, meteorological information, drug use, case reports) to direct the timely delivery of drugs and insecticides to affected regions.
Measles is the number one vaccinepreventable killer of children worldwide, despite the availability of an effective, inexpensive vaccine for more than 40 years. Measles continues to kill more than half a million children each year, out of 30 to 40 million annual cases.9 Approximately 98% of these deaths occur in developing countries. Measles mortality risk is increased among younger children and those with malnutrition, especially vitamin A deficiency. Measles also frequently leaves children weakened, malnourished, and vulnerable to subsequent infections and death.
In theory, measles, like smallpox, can be eradicated, because there are no nonhuman hosts or reservoirs and the virus does not remain infectious for long periods in the environment. However, measles eradication is proving challenging for three main reasons: it is highly infectious (more so than smallpox); vaccination rates are not high enough; and vaccination is only partially protective when given to infants younger than 1 2 months.
Nonetheless, great progress has been made in reducing measles mortality. The United Nations Children's Fund (UNICEF) recently announced a global reduction of 30% in deaths from measles between 1999 and 2002, and specifically a 35% reduction of deaths in Africa, where most measles mortality occurs.10 One of the primary strategies in achieving this reduction has been the use of Supplemental Immunization Activities, similar to National Immunization Days for other vaccines, conducted every 3 to 4 years, in which attempts are made to immunize every child ages 9 months to 5 years during a I- to 2-week period.
In the worst-affected countries, national HTV/AIDS prevalence rates are now about exceed 40%. The pandemic continues to take a heavy toll on children by infecting them, making them orphans, and disrupting the economies and healthcare systems where they live. The Joint United Nations Programme on HTV/AIDS estimates that, worldwide in 2003 among children younger than 15, about 2.5 million children were living with HIV/AIDS, half a million died, and 700,000 were newly infected."
The majority of these children are in subSaharan Africa, where most children have acquired infections from their mothers, who had been infected by heterosexual transmission. Although interventions such as antiretroviral drug therapy and exclusive breastfeeding with abrupt weaning at approximately age 4 months have the potential to stem mother-to-child transmission, these strategies remain difficult to implement.
As of 2002, the pandemic also has orphaned more than 13 million children by claiming one or both parents, and this number is projected to rise to more than 25 million by 20 10.12 In several African countries, the disease has already orphaned more than 15% of all children.12
In addition, HIV/AIDS, by sickening and killing so many young adults, depletes countries of their workforces, thereby consuming billions of dollars worth of economic activity and impoverishing nations and families. By creating legions of sick people, the pandemic has diverted scarce healthcare resources that could otherwise have gone to the prevention and treatment of other important childhood illnesses.
Perinatal and Neonatal Morbidity and Mortality
Approximately 4 million infants die every year in the neonatal period (the first 28 days of life);13 another 4 million die in the third trimester of pregnancy.2 Unlike overall childhood mortality rates, neonatal mortality rates have declined very little in recent decades. Two-thirds of all deaths before age 1 , and more than one-third of all deaths in children younger than 5, continue to occur during this first month of life.
Neonates have a 10- to 15-fold greater chance of dying than during the rest of the first year of life. The first week of life is particularly hazardous and accounts for two-thirds of deaths within the neonatal period. Approximately 98% of all perinatal deaths occur in developing countries. These deaths are due primarily to infections (32%), birth asphyxia and injuries (29%), and complications of prematurity (24%).2
Not surprisingly, the health and survival of these infants is closely linked to the health of their momers. For example, low birth weight, which is frequently the consequence of poor maternal health, is an underlying factor in 40% to 80% of neonatal deaths.2 Successfully preventing these deaths will therefore require improvements in the care of both mothers and infants.
LEADING RISK FACTORS
International child health can also be examined from the viewpoint of risk factors leading to poor child health. Among the most important risk factors are malnutrition, inadequate water and sanitation, and poor hygiene. More recently, other important factors have also been cited, particularly indoor air pollution from the combustion of lowquality household fuels such as wood.
Malnutrition clearly is the leading global risk factor threatening the health of children. In fact, undernutrition has remained the single most important cause of health loss worldwide during the past decade, accounting for 9.5% of the world's total disease burden, measured in terms of Disability Adjusted Life Years.14
Malnutrition can be severe, taking the forms of marasmus and kwashiorkor. In reality, however, most of the morbidity and mortality is due to milder forms of malnutrition such as mild to moderate underweight, as well as micronutrient deficiencies, especially of iron, vitamin A, zinc, and iodine.
Inadequate Safé Water, Sanitation, and Hygiene
Poor sanitation, hygiene, and water quality account for the deaths of approximately 1 .5 million children each year, mostly through diarrhea. The World Health Organization (WHO) estimates 1 . 1 billion children and adults drink unsafe water.15 Lack of readily available safe water supplies also contributes to reduced school attendance because children are often responsible for fetching water.
Roughly 2 billion people lack safe sanitation facilities, a problem which in turn also contributes heavily to diarrhea. As noted above, poor hygiene practices, such as insufficient hand washing, also are strong contributors to poor child health.
Exposure to Indoor Smoke from Solid Fuels
About half of children worldwide live in homes that cook and heat with fuels such as grasses, animal dung, wood, charcoal, coal, and kerosene. These fuels typically are burned in indoor open fires or smoky, inefficient stoves that emit large amounts of hazardous combustion products. As a result, children suffer from pneumonia and other respiratory illnesses, and also probably from low birth weight, stillbirth, and meningitis.
Many children suffer burns at home or are injured or exposed to vectorborne diseases while collecting fuel. They also are affected indirectly when their caregivers become ill with smokerelated diseases such as chronic bronchitis and respiratory tract cancers. The resulting burden of disease among people of all ages is staggering; for those in high-mortality developing regions, indoor smoke exposure is the fourth leading risk factor for disease (following underweight, unsafe sex, and unsafe water/sanitation).14 Given the amount of time young children spend indoors, the relative risk is likely even higher for children.
Lack of Vaccines
One practical way in which poverty translates into poor child health is lack of funds to provide vaccines. At least 70% of all childhood deaths are believed to be vaccine preventable, but each year about 30 million children are born who will have no access to vaccinations. Existing vaccines for common diseases such as measles, tetanus, pertussis, and Haemophilus influenzae type b could save the lives of an additional 1 .5 million lives if more children could be reached. Another million children could probably be saved if vaccines against pneumococcal disease and rotavirus were added. Unfortunately, resources are not available to safeguard all these children.
There have been, however, some remarkable vaccine successes. Poliomyelitis transmission has been sharply curtailed, and as ofAprì 2004, endemic wild-type transmission has been interrupted in all but six countries (Afghanistan, Egypt, India, Niger, Nigeria, and Pakistan).16 If political will and funding remain adequate, polio may well be eradicated worldwide wimin a few years.
SOCIAL PROBLEMS AFFECTING CHILD HEALTH
Another way to view the health problems of children around the world is to examine the social problems that contribute to poor health. Here, we will examine just three of the most important issues - poverty, armed conflict, and lack of education.
Poverty harms the health of children through a multitude of direct and indirect mechanisms. National poverty means lack of funds for healthcare, water and sanitation, education, and family assistance programs. Household poverty results in food insecurity and malnutrition and inability to afford health care services or education. Poverty forces families to live in unsafe areas and use unsafe, polluting household fuels.
Household poverty also frequently forces families to migrate or break up when one or both parents move in search of work. It is frequently at the root of child labor and the sexual exploitation of children. An excellent, comprehensive review of the many facets of the poor-rich health divide and approaches to improving the health of the world's poorest citizens has recently been published as a bulletin by the Population Reference Bureau.17
In most of today's conflicts, civilian casualties significantly outnumber those of combatants, and children are disproportionately affected. 18 UNICEF reports that by the end of the 1980s, 90% of war victims were civilians,19 and that in the past decade, 2 million children have been killed by conflict, 12 million have lost meir homes, and 4 to 5 million have been injured or disabled.20 One reason for this shift is that most conflicts now are within instead of between countries, and battles are fought in villages and suburbs, making the distinction between combatants and civilians less clear. In some cases, ethnic hatred has M spawned intentional ef- A forts to eliminate entire à ethnic groups, including women and children.
Children are not just physical victims of conflict violence. They also are increasingly recruited as child ^ soldiers who work in a variety of capacities. UNICEF defines a child soldier as any child, male or female, younger than 1 8, who is part of any kind of regular or irregular armed force or armed group in any capacity, including but not limited to cooks, porters, messengers, and anyone recruited for forced sexual purposes or forced marriage. It also includes anyone accompanying such groups, other than family members. At least 300,000 child soldiers are engaged in about 30 different conflicts globally,21 where they suffer abuse, rape, and psychological trauma.
Lack of Education
Children's health is linked closely to the education of children and their parents, especially their mothers. More than 120 million primary-school-aged children worldwide do not attend school. Sometimes, schools are not available in an area, but more often, it is family poverty that keeps children from attending. Children may be forced to work to contribute to family income.
In many developing countries, even government-run "free" public schools charge fees for supplies such as uniforms and books that can be unaffordable to the poorest families. In addition, children may be required to have a birth certificate to enroll. Children born at home to poor parents may never have had their births registered because fees of even a few dollars can be prohibitive. For children who are able to attend school, prolonged periods of school closure due to teacher strikes, regional conflicts or political unrest are all too common, severely detracting from the quality of education.
If a family can afford to send only one child to school, often a son is chosen before a daughter. Worldwide, in fact, approximately 60% of the children who are not in school are girls. SubSaharan Africa, south Asia, east Asia, and the Pacific are the regions with the greatest number of girls not attending school.22 As a consequence, two-thirds of the world's 875 million illiterate adults are women.14
In recent years, attention has focused on the particular health benefits of educating girls. Girls who have attended school tend to marry later and have fewer children. Their children are better nourished and more likely to receive immunizations. According to a World Bank review from various countries, each year of maternal education decreases the mortality rate of their children before age 5 by 5% to 10%.23 Every year of schooling also increases individual wages (for both men and women) by about 10% and reduces the risk of maternal mortality during childbirth. Women who have attended school have better nutrition in pregnancy and are more likely to seek prenatal and delivery care. Every additional year of schooling means fewer births and prevents about two maternal deaths for each 1,000 women.24
The International Labor Organization, in its recent report titled "Investing in Every Child," estimated it would cost about $760 billion by the year 2020 to provide universal primary education.25 This figure includes building and staffing additional schools, government payments to families to compensate mem for the lost value of their children's labor, and rehabilitation of children working in bondage and prostitution. As large as the amount is, the key finding reported is that there would still be a worldwide financial net gain of $4. 1 trillion in 2 decades due to increased productivity and decreased medical costs.
EFFORTS TO IMPROVE CHILD HEALTH
International Financial Aid for Health
Many of the world's 200 or so countries can afford to spend only $25 or less per person per year on health. This figure contrasts sharply with the $5,000 spent in the US. Wealthy nations now provide about $4 billion per year in official development aid specifically for health to poorer nations, translating into about $1 each year for each person living in the developing world.26
The $4 billion includes loans for health activities but does not include some forms of development assistance that can affect health, such as education, water, and sanitation. Nevertheless, this amount of assistance, equivalent to about half of annual expenditures in the US on cosmetics or about one-third of what Europeans spend on ice cream each year, falls far short of the amounts needed to provide even rudimentary health services to all of the world's children.
International Initiatives for Children
Faced with chronic funding shortages and lack of political will for decades, the international child health community has struggled to find ways of making the best possible use of available resources and to gain more political and financial support. One of the most important developments was the creation of UNICEF in 1946; the organization has been a powerful advocate and leader for the world's children. Another crucial development for international child health was the adoption of the Declaration of the Rights of the Child in 1959,27 which enshrined into law protections for child health and spawned decades of subsequent political and legal activities protecting children. The Convention on the Rights of the Child was later adopted by the United Nations General Assembly, in 1989.28
Another milestone was the Primary Health Care movement, whose doctrine was codified at the 1978 conference at Alma-Ata in what was then the Soviet Union.29 It outlined a vision for "essential health care made universally accessible to individuals and families in the community." At the same time, research was under way around the world to find inexpensive but effective ways to save and protect children.
While waiting for the political and financial resources required to fulfill the promise of Alma-Ata, the international child health community attempted to design and implement strategies of selected interventions that could make the most of existing resources to help children. The GOBI concept - Growth monitoring, Oral rehydration, Breastfeeding and Immunization - and the Child Survival and Development Revolution were two of the most important such initiatives launched in the early 1980s.30 In 1987, the Safe Motherhood Initiative was launched.31
In the early 1990s, international will to protect children was again expressed in three major ways. First, in 1990 the World Summit for Children brought the Convention of Rights of the Child into force, further strengthening legal protections for children.30 Next, in 1991 the Baby-Friendly Hospital Initiative was launched with the goal of establishing improved breastfeeding programs at hospitals.32
Then, in 1992, the Integrated Management of Childhood Illness strategy was developed by UNICEF and WHO,33 providing a protocol for health workers that combines curative care as well as disease prevention and health promotion. This program teaches a set of interventions that promote rapid recognition and effective treatment of the most important high-mortality diseases of children, such as pneumonia, diarrhea, and malaria. The initiative emphasizes prevention of health problems by promoting better nutrition (including vitamin A and iron supplementation), vaccination, use of insecticide-treated bed nets, and deworming. Other components of the program help improve health systems and support family and community practices that are most helpful to improving child health. This strategy has continued to be developed and expanded during the past decade.
Probably the most important recent initiative in international child health was the establishment of the United Nations Millennium Development Goals, launched by the UN General Assembly in September 2000.34 By this declaration, all 191 UN member states pledge, by the year 2015, to meet a series of goals, most of which pertain directly or indirectly to children's health (Sidebar, see page 652).
Interventions With Greatest Potential
In the summer of 2003, Lancet published a five-part series of articles on child survival and the current status of child health. The authors were child health experts assembled by the Rockefeller Foundation, known as the Bellagio Study Group.
The second article in the series examined what specific preventive and treatment interventions worked to improve child survival.35 Preventive interventions with the greatest potential effects include breastfeeding through the first year of life; appropriate complimentary feeding (foods given at age 6 months to 1 year in addition to breastfeeding); micronutrient supplementation (vitamin A and zinc); insecticide-treated bed nets in areas of malaria; immunizations (Haemophilus influenzae type b, measles, and tetanus); neonatal care (clean delivery and newborn temperature management); and safe water and sanitation. Therapeutic interventions with the most effect include oral rehydration therapy; appropriate antibiotic treatment (for pneumonia, dysentery, and neonatal sepsis); anti-malarial drug treatment; and use of zinc supplements during diarrhea.18
The authors concluded approximateIy two-thirds of child deaths could be prevented by such interventions, which are already available and feasible for implementation in developing countries at high levels of patient coverage. Without waiting for new drugs, vaccines, or technologies, we can use what interventions we already have to achieve the Millennium Development Goal of reducing the mortality rate of children younger than 5 by two-thirds by 2015.
Children in developing countries bear most of the burden of childhood death and disease. Because decades of technical and medical research have produced solutions to most of the serious health problems affecting such children, the main challenge ahead remains one of implementation. Achieving this goal will almost certainly require significantly greater commitment by the nations, organizations, and individuals who have the ability to help.
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