Jogindar died in India when she was two weeks old. She had persistent diarrhoea that caused her to become dehydrated. If someone had given her mother simple advice to breastfeed exclusively for the first six months of her baby's life and not to risk giving her water that might be contaminated, then Jogindar might have been saved.
Fahad, from Pakistan, aged four, died from malaria after an infected mosquito bite. If someone had given his family mosquito nets dipped in insecticide for the children to sleep under, Fahad might have been saved.
These are only examples of scenarios that are far too real. According to public health specialists writing in a new Child Survival series in the medical journal The Lancet, six million children under the age of five die because simple preventive measures and medical treatments are not delivered to them. In other words, we have the medical know-how, we just don't have the political will to deliver it. As one of the series co-ordinators, Cesar Victora from the University of Pelotas in Brazil, said recently at the launch press conference, 'We have the magic bullets but not the magic guns.'
Child deaths are usually the result of several risk factors but diarrhoea, pneumonia and neonatal problems are the biggest killers of children under five. Malaria kills a substantial number in some sub-Saharan African countries, and Aids in up to ten countries (see box).
Undernourishment is the basic cause of over half of child deaths, with 99 per cent occurring in poor countries. Over half of deaths occur in just six states - India, Pakistan, China, Nigeria, the Democratic Republic of Congo and Ethiopia.
Call for leadership
What many would see as the natural champion for child survival, the United Nations Children's Fund, was criticised at the launch. UNICEF 'was doing a great job in the 1980s', according to series co-ordinator Jennifer Bryce, from the World Health Organisation's department of child and adolescent health and development. 'Now it has abandoned child survival as the issue and is focusing instead on child labour, children's rights. There's a void.
It is no longer doing what it should be doing. Why should the WHO step in when there is UNICEF?'
A stand is being made now with a call for international leadership because child mortality figures worldwide have got worse since the 1980s - a result, say the series authors, of misplaced values, priorities and impractical delivery. When asked whether it is a matter of getting more medically trained staff out into the field to deliver simple medical treatments and preventive care, author Dr Saul Morris of the London School of Hygiene and Tropical Medicine, says, 'Wherever you are in the world, there is some kind of contact with the community. But it is very fragmented, it's not being properly integrated. International organisations split diseases up and treat them individually, rather than thinking of the whole person in a holistic manner. The medical profession does the same.'
He comments particularly on the attention and effort being directed at the 3 per cent of under-fives dying from AIDS, when over seven times as many children die from diarrhoea and pneumonia. More than a third of child deaths occur in the first 20 days of life, which could be greatly reduced with more postnatal support.
Success stories
The knowledge base for implementing the effective delivery of simple medical treatments for children is scattered. General guidelines can be abstracted from small-scale studies and field experience, say the Lancet authors, but the evidence is not complete and has not yet been synthesised into a coherent whole. A major research project is recommended on how to effectively scale up the successful experiences of many local projects.
For example, a project in Tanzania successfully involved shop owners and the public health sector in promoting insecticide-treated mosquito nets, which led to a 27 per cent reduction in mortality among children who used the nets. In Guatemala, a project where health workers with secondary education were trained in the management of common childhood illness led to a reduction in deaths among children aged one to four from 28 per 1,000 children to six per 1,000 in only three years.
What's needed now
The child health specialists are calling for leadership from UNICEF, WHO, the World Bank and UN development programme and their UN partners, with support from national governments. On a practical level, they conclude that data on the causes of death needs to be collected by country rather than region to tailor community healthcare effectively. And a review process is needed to hold organisations responsible for delivery accountable.
Officially, UNICEF has given a robust rebuttal of the charge that the organisation made no progress in the 1990s, while admitting that there is a 'diffuse set of views as to how to move forward'. Chief press officer Alfred Ironside says that UNICEF's first two priorities are early childhood development and the spread of immunisation and micro-nutrients. Other priorities are education for all children, especially girls, and the prevention of HIV and Aids.
He says, 'We're working hard on simple interventions already, but they are home-based, and what is needed for long-term gains is education. We're making efforts to get girls into school - where girls are not in school there is high infant mortality. If we educate girls year after year they will be more capable mothers. Where parents have Aids, children are orphaned. We don't see the work on Aids as a distraction. There is a disagreement here.'
However, one of the series authors, Dr Gareth Jones from UNICEF's own division of policy and planning, disagrees. The paper 'How many child deaths can we prevent this year?' concludes, 'Amid the plethora of new and newly validated interventions, there are signs that the child survival effort has lost its focus. For example, levels of attention and effort directed to preventing the small proportion of child deaths due to Aids with a new, complex and expensive intervention seem (although no investment data are available) to be outstripping the efforts to save millions of children every year with a few cents' worth of insecticide-treated materials, oral rehydration therapy, or efforts to promote breastfeeding.
This must change.'
Long-term education must go hand in hand with immediate prevention, it would seem. Or, as Jennifer Bryce colourfully puts it, 'When the trailer goes out to look for women with HIV, why not put someone in it who knows how to treat children with diarrhoea?'
* Read the Lancet series in full at www.thelancet.com
INFORMATION
Overall co-ordinators for the Child Survival series
* Jennifer Bryce, Department of Child and Adolescent Health and Development, World Health Organisation, Geneva, Switzerland
* Professor Cesar Victora, University of Pelotas, Brazil
WHAT THE LANCET AUTHORS SAY
* 10.8 million children aged under five die each year, almost all from poor countries.
* Six million of these could be saved by simple medical treatments that cost only pennies.
* In 42 countries with 90 per cent of under-five deaths, the authors attribute 22 per cent of all child deaths to diarrhoea, 21 per cent to pneumonia, 9 per cent to malaria, 3 per cent to Aids and 1 per cent to measles.
* Healthcare funding is allocated to separate diseases, such as Aids. This prevents us looking at young children holistically.
* The effort to reduce child mortality in the 1980s that saved millions of lives has fallen off the international agenda and funding has decreased in relative terms.
* Between countries, differentials in child mortality rates are rising instead of falling. In 1990, the child mortality rate in sub-Saharan Africa was 180 per 1,000 live births compared with only 9 per 1,000 in industrialised countries - a 20-fold difference. By 2000, the gap had increased to 29-fold.
* The Millennium Development Goal of reducing under-five mortality by two-thirds by 2015 is unlikely to be met.
* World Health Organisation (WHO) has a new leadership in July.
