Only about 3% of the world's 2 billion children live in the United States, while 90% are now bom in developing countries. Children not only make up a much higher proportion of the total population in developing nations but also face a much higher burden of disease than their brothers and sisters in the developed world. In fact, each year, about 1 1 million children younger than 5 die worldwide, almost all in developing countries, and most from easily preventable or treatable diseases.
The major killers of these children are acute respiratory infections, diarrhea, malaria, measles, and malnutrition. The greatest numbers of deaths occur during the perinatal period, from birth complications, low birth weight, infection, and congenital defects.
Why should we as pediatricians be interested in the health problems of children in developing countries? One need look no further than the demographics of our own practices to appreciate that we are seeing more and more children from recently immigrated families. In addition, the number of internationally adopted children has risen sharply. For example, in the US, it has quadrupled from about 5,000 in 1992 to now more than 20,000 each year. Moreover, as we grow ever more mobile, we are taking care of more patients who travel to developing countries for family vacations, to visit family, or to study abroad.
For those of us working with medical students and residents, the increasing interest in global health issues among our young doctors-intraining is quite evident, with more and more students and residents seeking électives abroad during their training. Thus, even for pediatricians with a domestic focus, or not planning volunteer medical work abroad, knowledge of the diseases and social conditions affecting these children has become necessary in our everyday practices.
On a broader humanitarian level, and as stated by the motto of the American Academy of Pediatrics, pediatricians are, after all, "dedicated to the health of all children," and we simply cannot focus only on the tiny minority fortunate enough to live in wealthy countries. Just as we recognize that the optimal care of our young patients must include a wider consideration of the child's family, similarly, the health and well-being of a nation's children collectively must include a broader consideration of health conditions around the world. Countries whose children grow up with adequate maternal care, nutrition, water and sanitation, education, and healthcare will almost certainly produce wiser leaders and make better neighbors than those whose children grow up in desperate circumstances. It would seem, therefore, to be in everyone's best interest to address global health inequalities.
The under-5 mortality rate (U5MR) is a widely used indicator of the state of a nation's children, because it represents mortality risk during the most vulnerable years of childhood. It is the annual number of deaths in children younger than 5 per 1,000 live births. The overall world average is about 80. For industrialized countries, the average is about 7, and for the least developed nations, the average is approximately 160. Rates above 100 are considered quite high. During the second half of the last century, mortality rates for young children dropped steadily; however, the pace of the decline has slowed in the past decade, and in some regions there has been no improvement, or even an increase in childhood mortality.
During the World Summit for Children in New York in 1990, when the global average U5MR was approximately 85, leaders from over 150 nations established a goal of reducing this rate to 70 by the year 2000. More than 50 countries have not met this target, and 10 countries continue to have U5MRs of over 200: Afghanistan, 264; Angola, 201 ; Guinea, 205; Guinea-Bissau, 202; Liberia, 205; Malawi, 219; Mali, 235; Niger, 335; Sierra Leone, 312; and Somalia, 20 1.1
ECONOMICS, POLITICS, AND CULTURE
Factors most correlated with declines in childhood deaths include improved nutrition, water and sanitation, access to healthcare during pregnancy and birth, appropriate care for diarrhea, availability of electricity, and female education. Factors contributing to the stagnation in improvement include lack of economic growth, war or civil conflict, inappropriate choices of health interventions, and the HIV/AIDS epidemic. Therefore, when discussing international child health, it is important to keep in mind that the health of children is not determined merely by disease but also by economic, political, and cultural forces. Poverty and the ever-widening gap between rich and poor, both within and between nations, also remain critical underlying factors in poor child health in most regions.
Politics, for example, determines what legal protections and resources are allocated to child health, the extent of cooperation among states and organizations, whether conflict disrupts the society, and, to a large extent, what kind of economy is present. Culture determines the priorities placed on children and specifies who makes the decisions about their health. Cultural forces also determine how health and illnesses are perceived within a society and, in turn, what kinds of prevention and treatments (eg, science-based, herbal, spiritual) are sought. Parents may have very little correct information on how diseases occur or what they can do about prevention or treatment. Culture, therefore, helps determine what hygiene practices are followed and what foods are consumed; it even influences how some diseases such as HIV/AIDS and tuberculosis (TB) are transmitted.
Economics, politics, and culture combine to determine the practices of child labor, the use of children as soldiers, and the trafficking and abuse of children. They also influence the degree of migration, which at present is primarily rural to urban and which can disrupt the normal supportive social structure, leaving children vulnerable to drug abuse and sexual exploitation. Geography and climate determine the range of vector-borne illnesses such as malaria, whether the soil has enough iodine to grow nutritious crops, or if it is warm and moist enough for the ground to harbor hookworm larvae.
Delineation of these direct and indirect determinants of child health helps guide where interventions might effectively be applied. For the most part, solutions directed toward each of these determinants have been developed that could alleviate most of the death and serious disease among the children of the world. The issue now is primarily one of implementation. Thus, at present, the health of children rests heavily on the interest and generosity of individuals, organizations, and nations who have the resources to help.
CHILD HEALTH RISK FACTORS
Child health can be gauged not only by looking at the magnitude of the morbidity and mortality caused by specific diseases and injuries but also by estimating the effects of certain risk factors such as undernutrition or lack of vaccinations. While such estimates frequently are useful, it is important to remember that accurate data on many important aspects of child health are still lacking because many countries cannot afford the required surveys and reporting systems. In addition, the effects of many key health-related risk factors, such as environmental degradation or lack of education, are quite complex and therefore difficult to assess. In spite of these limitations, much has been learned in recent years about the complex web of factors affecting child health.
WHAT CAN PEDIATRICIANS DO?
We as pediatricians must continue to educate ourselves and others about the grave injustice of health inequities globally. We must especially ensure that international child health issues are addressed in pediatric residency curricula, so that we capitalize on residents' enthusiasm and idealism and continue to expand the numbers of informed pediatricians. We must make our voices heard by our political leaders, insisting that the wealthier nations take the lead in the global battle against diseases such as malaria, TB, and HIV/AIDS. It is the pediatricians who must lead the leaders in keeping maternal and child health issues in the forefront.
On an individual level, we must support nongovernmental organizations working to improve child health in developing nations. We should further consider volunteering our time overseas to help in whatever capacity our expertise permits.
We also must address the "10/90 Gap" in health research funding allocation. Of the roughly $70 billion in public and private funds spent globally on health research each year, only 10% addresses the illnesses that cause 90% of the world's burden of disease. We must find ways to encourage young scientists and pharmaceutical companies to work on research aimed at reducing the toll from diseases such as malaria, TB, and HIV/AIDS, as well as to study better ways of implementing the strategies we already know work in reducing child mortality.
Investing in child health, nutrition, and education will bring about one of the best returns on the dollar in terms of lives saved. Delaying such investments only makes the situation harder to tackle in the future. Surely this investment is one of the most cost-effective that we can make to help low-income nations achieve long-term stability and prosperity and to show our good will and concern for the children of all nations, rich or poor.
IN THIS ISSUE
This issue of Pediatric Annals takes a broad view of international child health, concentrates on the major problems of children in the developing world, and explains some current strategies for improvement, given the limited resources now available. Our article, "Protecting Child Health Worldwide," provides an overview of these topics.
Malnutrition is highlighted in Dr. Neumann's article, "Child Nutrition in Developing Countries," because it is a factor in more than half of the deaths among children younger than 5 each year. The psychosocial aspects of caring for children with severe malnutrition also are presented.
With one in every three people in the world infected with Mycobacterium tuberculosis, tuberculosis remains a hidden epidemic among children in the low-income countries. The article by Dr. Adams, "Childhood Tuberculosis in the Developing World," addresses the difficulties in identifying and treating childhood tuberculosis. Several cases are presented from South Africa in "Childhood Tuberculosis: Reflections from the Front Line," by Dr. Marais.
For pediatricians who care for patients who travel internationally, Dr. Christenson's article, "Preparing Children for Travel to Tropical and Developing Regions," provides an excellent summary of what we need to know to help our patients stay healthy while abroad. Dr. Norton's article, "International Child Health for the Practicing Pediatrician," offers many different ways busy pediatricians can become involved in international health projects, including advice on volunteering overseas. In "Pediatricians and the Rights of the Child " Dr. Kasper helps familiarize us with the key aspects of the United Nations Convention on the Rights of the Child, a most important international document safeguarding the health and well-being of all children. Finally, we learn about the life-changing experiences of a pediatric resident, Nooshin Razani, who worked in Bam, Iran, after the recent earthquake there.
It is our hope that this issue of Pediatric Annals will stimulate among readers a desire to learn more about the difficult challenges faced by our colleagues who live and work in developing countries. They do so much with so little, and their dedication to their work is an inspiration to us all. Armed with such information, working as individuals and as members of political, educational, charitable, and service organizations, we can help many of the children who otherwise will be lost without our attention.
1. Ahmad OB, Lopez AD, Inoue M. The decline in child mortality: a reappraisal. Bull World Health Organ. 2000; 78(10):! 175-1 191.