In the fight to cut infant mortality, is the world focused on the wrong diseases?
For Ashok Talyan, putting children first is more than a sentimental idea. With him, it’s a question of pragmatism.
Dead and dying children are a part of daily life for Talyan, a 32-year-old physician and district medical officer in Uttar Pradesh, India’s most densely populated province.
Twenty-three per cent of children in Uttar Pradesh die before the age of five — 30 times the average in wealthy nations like Canada.
On a tour last summer of one of the medical clinics Talyan works at in Adampur, a village of 7,000 where families live in crudely constructed huts without running water or electricity, it wasn’t hard to see why so many young kids are dying.
The village’s government-run clinic has only a few beds. The families of patients — mostly children dying from parasitic diseases, pneumonia or diarrhea — must pay for all the drugs. The water in the clinic is polluted. Electricity is only available a few hours a day.
“Most of these kids wouldn’t get sick if a dollar or two per person annually was spent on public health in the region,” Talyan said.
The situation offers insight into India’s greatest human tragedy: More than a million newborns die in India annually. A further 1.5 million children die before the age of five from diseases of all kinds.
But India is just part of a larger global tragedy: More than 10 million children under five die each year worldwide. Ninety per cent of those deaths are concentrated in the world’s 42 poorest countries.
Almost all of these children die from easily and inexpensively preventable diseases, a fact that is causing critics to complain that efforts to wipe out AIDS, malaria and polio — the “gang of three,” as one UN adviser calls them — are consuming a share of international health aid resources disproportionate to the number of lives saved.
“The national health systems in many disease-ravaged countries need to be strengthened to tackle basic problems like diarrhea and pneumonia,” says Harvard University researcher Catherine Michaud. “That effort needs to be better balanced with existing programs” like those tackling AIDS, TB, malaria and polio.
Michaud hastens to insist that not a cent of the money currently directed towards AIDS and other diseases should be diverted. What’s needed, she says, is new money for new programs to tackle children’s health.
In 2000, the member states of the United Nations committed to reducing child mortality by two-thirds — seven million deaths — by 2015. They also committed to reducing maternal mortality by three-quarters. Those commitments are part of a global drive to reach seven key international development objectives known as the Millennium Development Goals.
With the clock ticking toward 2015, international aid researchers such as Michaud are calling for a rethink of how wealthy nations deliver health aid to countries where massive numbers of mothers and children die from easily preventable causes.
In recent years, new funding for international health programs has mostly been directed toward AIDS, tuberculosis, malaria and polio. The Global Fund to Fight AIDS, Tuberculosis and Malaria was established under UN leadership in 2002; to date, 27 nations and 30 corporations and philanthropic groups have pledged $4.7 billion to it.
Under UN leadership, $4 billion in international aid has also been devoted to polio eradication since 1988.
And in 2003, the Bush administration launched a five-year, $15 billion AIDS plan. But there is no co-ordinated international fund or effort to fight diarrhea and pneumonia, even though health researchers increasingly argue much more money should be spent tackling these cheaply treated diseases.
According to a 2003 study by Robert Black, a professor of international health at Johns Hopkins University, diarrhea and pneumonia account for 43 per cent of deaths of children under five, while malaria accounts for nine per cent, and AIDS for just three per cent.
Another study by UN Millennium Project director Jeffrey Sachs and vaccine researcher Peter Hotez suggests a group of “neglected tropical diseases” — mostly water-borne parasitical diseases such as schistosomiasis and hookworm — threaten the poor in Africa and Asia in roughly similar measure to HIV/AIDS, TB, or malaria.
Sachs and Hotez point out that, unlike costly programs required to fight AIDS and TB, many common killers can be defeated for less than $1 (U.S.) per person annually. They say 500,000 lives, mostly children’s, could be quickly and cheaply saved if aid programs were expanded to include the neglected diseases they investigated.
Numerous international health researchers agree. In a series of papers published since 2003 in Britain’s two leading medical journals, The Lancet and British Medical Journal, scores of scientists support what Richard Horton, editor of The Lancet, calls “the coming decade for global action on child health.”
Over 10 million under-five deaths had been ignored for far too long by governments and even international agencies,” Horton says. “Three years ago, a group of concerned child-health experts proposed not only to synthesize knowledge about child survival but also to catapult the child back onto the policy map of global health.”
Jennifer Bryce, a freelance community health researcher in Ithaca, N.Y., can take much of the credit for that success.
`The biggest killer is not malaria, or AIDS or TB. It’s pneumonia, which is easily treatable with cheap antibiotics supplied by trained people in strengthened public-health systems’
After 10 years helping co-ordinate child mortality research for the World Health Organization in Geneva, Bryce resigned two years ago in order to speak freely in a series of Lancet articles co-authored with researchers from Brazil, Pakistan, the U.K., the U.S. and the WHO.
Bryce says millions of easily and cheaply preventable children’s deaths have been overlooked amid massive international concern about AIDS, TB, malaria and polio. In a Lancet study titled “Can we afford to save the lives of 6 million children each year?” Bryce and her colleagues argue that only $5 billion in additional aid — about $877 per child saved — is required to achieve much of the two-thirds reduction in child mortality agreed upon by world leaders in the Millennium Development Goals.
These figures are based on a decade’s worth of evidence gathered by senior researchers around the world indicating that the biggest killers of children are pneumonia and diarrhea, both of which can be easily and cheaply suppressed in even the poorest nations.
“Five billion dollars is affordable,” Bryce and her colleagues argued in their eight-page paper. “It reflects a choice being made by policymakers and donors — a choice that allows 6 million children to die each year, over 16,000 each day.”
On the phone from Ithaca, Bryce is even more emphatic.
“Child survival missed the media boat,” she says of the massive attention devoted to AIDS and other high-profile diseases. “The biggest killer is not malaria, or AIDS or TB. It’s pneumonia, which is easily treatable with cheap antibiotics supplied by trained people in strengthened public-health systems. We can save millions and millions and millions of kids with things that are not fancy.”
Speaking from Pelotas in southern Brazil, epidemiologist Cesar Victora strongly agrees. Victora says the methods he and Bryce advocates were implemented long ago with striking results in Brazil and several other nations.
“We’ve had massive increases in child survival figures,” he says about Brazil. “With bolstered public health services, we tackled diarrhea and pneumonia. These simple steps saved millions and millions of lives.”
At the WHO, David Evans has a further arsenal of scientific evidence to offer in support of the growing chorus of calls for rapid, cost-effective action to save children’s lives.
Evans co-authored a series of five papers in the British Medical Journal last year arguing that the Millennium Development Goal to reduce child mortality is doable without great expense through programs distributing vitamin A and antibiotics for pneumonia, along with breastfeeding promotion, bolstered re-hydration programs for diarrhea patients and training for birth attendants and midwives.
UNICEF, meanwhile, estimates recent efforts to promote breastfeeding currently save 6 million lives a year. Even so, UNICEF estimates only 39 per cent of infants in developing countries are exclusively breastfed, suggesting a further two million children per year could be saved through universal breastfeeding.
A UNICEF pilot project underway in 11 West African nations strongly bolsters the science behind the new child-survival crusade.
Launched in 2002 thanks to a $30-million grant from the Canadian International Development Agency (CIDA), the project provides a package of health programs to 17 million people in West Africa.
UNICEF calls its approach the Accelerated Child Survival and Development Program; it is largely based on the research marshalled by Bryce and Evans.
The package concentrates on distributing vitamin A and anti-malarial insecticide bed nets (malaria is a major killer in Africa), along with boosting routine immunization programs, promoting breastfeeding, and bolstering re-hydration programs for children with diarrhea.
Rudolf Knippenberg, UNICEF’s chief health advisor, calls it the most important push worldwide to prove the UN goal of reducing child mortality by two-thirds is realistic and cost effective.
“It’s a very down-to-earth approach that balances the needs for simple health technologies, improved public health systems, and modestly increased funding for child survival,” Knippenberg says.
The results of the pioneering, Canadian-funded effort have been very encouraging so far: 20 per cent of child deaths have been prevented — a percentage that amounts to 18,000 lives saved annually, at a cost of about $500 per life.
Knippenberg says UNICEF now hopes to extend the program across the entire continent of Africa and is negotiating with the Canadian government for new funding.
“Given the results which have been achieved, we’re very keen to discuss further options with UNICEF,” CIDA spokesman Pierre Naud said last week.
Partly to help promote that effort, UNICEF is flying Sir Roger Moore, the star of James Bond films such as Live and Let Die — to Toronto next week.
Knippenburg said he hopes the new Canadian government continues its leading role. “There’s no doubt,” he said, “that child survival is an idea whose time has come.”