Child Health Priorities in the 21st Century with Special Concern for Asia
The health problems of the world are changing; if current trends continue, the global importance of communicable diseases and malnutrition will decrease, and non-communicable diseases and injury will have assumed a far greater importance. However, for children, the projected distribution of causes of death will be much the same in 2020 as it was in 1990. The burden of ill health among children will continue to be dominated by diseases of under-development. The major causes of child deaths are acute respiratory infection, diarrhoea, measles, malaria, and malnutrition. This article addresses the five major life-threatening conditions, as well as perinatal/neonatal mortality, child mortality and HIV/AIDS, and additional health problems related to the consequences of urbanisation and changing lifestyles, and suggests what might be the priorities in dealing with them. It must be remembered that the five conditions mentioned above are a direct cause of 55% of all childhood mortality; this sad state is likely to remain so in 2020 unless action is taken now.
Keyword : Burden of ill health; Child abuse; Child health; Childhood HIV/AIDS; Communicable diseases; Genetic disorder; Lifestyle change; Malnutrition; Mortality; Noncommunicable diseases; Perinatal and neonatal: Priority: Urbanisation; Violence
The health problems of the world are changing. In 1990, almost half of the global burden of disease was due to three categories of illness: communicable diseases, problems of maternal health, and malnutrition. If current trends in disease incidence and in the major determinants of health status continue, in 2020 it is expected that these conditions will account for less than one quarter of human ill-health. Non-communicable diseases and injury will have assumed a far greater relative importance.
But among the world's children, the changes in the causes of disease burden will be much less dramatic. The projected distribution of causes of childhood death in 2020, globally, will be very similar to the pattern in 1990 (fig. 1).1
However this apparently unchanging picture masks considerable regional differences, the most marked being the different trends in Africa and Asia (fig. 2). In Africa, the absolute number of deaths is actually expected to increase slightly and the proportion due to the communicable diseases and perinatal causes remains constant. In Asia, by contrast, it is expected that mortality will fall very considerably and, although communicable diseases will still cause the largest proportion of deaths, the relative importance of noncommunicable diseases and injury will increase.
As the world enters the 21st century the burden of ill health among children will continue to be dominated by diseases of under development. In some parts of the world, however, diseases associated with increased development and changing lifestyles will assume a greater relative importance. This article addresses some of the major child health problems in each of these categories and suggest what might be the priorities in dealing with them.
Major Causes of Childhood Mortality
The first cause of childhood death world-wide is acute respiratory infection. The incidence of such infections is similar in all parts of the world, most children experiencing 4 or 5 episodes a year. But the proportion that lead to life threatening pneumonia is far greater in developing countries as is the proportion due to bacterial infection. Consequently the risk of death from an acute respiratory infection is many times greater than in industrialized countries.
The definitive solutions to this problem are better nutrition, better housing and reduced air pollution both indoor and outdoor. In the meantime, mortality rates can be substantially reduced by training all health workers in a simple approach to detecting and treating pneumonia and in making effective antibiotics available. A metaanalysis of studies conducted in 5 countries showed a reduction in acute lower respiratory infections mortality of 53% in children 1-4 years old and 35% in infants (fig. 3).2
Diarrhoeal diseases are the second cause of death among children despite widespread use of oral rehydration therapy to prevent and treat the dehydration they commonly cause. Here also the definitive solution is a long term one: improved water supply and sanitation. If the trends from 1990-1994 continue, the population without an adequate water supply will decrease qlobally but continue to increase in Africa.
For sanitation, the situation is worse. Unless improvements are accelerated, the underserved population will actually increase in all regions of the world, including in Asia and the Pacific where less than one third of the population will be served by 2020.3 These trends can only be improved by new and massive inputs. Clearly the health of the world's children cannot be protected without urgent attention to improving water supplies and, in particular, sanitation services.
Of the childhood diseases preventable by vaccines, measles has the highest death toll causing an estimated 800 000 deaths in 1995. The cornerstone of measles control is immunization. Measles vaccine isl customarily delivered through national programmes of childhood immunization usually comprising 6 or more antigens. These programmes are facing many challenges. In some countries immunization rates are actually falling from the levels attained in the late 1980's. Even in countries with sustained high coverage rates, reaching the uncovered populations is difficult and expensive. Vaccine costs are rising at the same time as developing countries are expected to become self-sufficient in vaccines. And even as countries struggle to provide the existing antigens to all children, new vaccines with strong public health justification are becoming available.
Other vaccines soon to be available include Haemophilis influenzae type b vaccine (recently shown in the Gambia to be highly efficacious), pneumococcal vaccines (soon to go into trials in Africa and Asia) and rotavirus vaccine. Many more vaccines are under development. As vaccines compete for a place as routine public health interventions it will be important to carefully examine their cost-effectiveness to inform policy making.
If these challenges can be overcome, the potential of vaccines is enormous. The successes already achieved against polio and measles are impressive. In 1988, more than 35000 cases of polio were reported globally. In 1996 the number was less than 2000 and in the Americas no case has occurred since 1991. Also in 1996 only 2 cases of polio were reported from China and these were imported cases. The fall in the number of reported measles cases is also impressive as vaccination coverage has risen from less than 20% in 1983 to almost 80% now (fig. 4).4
Malaria is also among the top 5 childkillers today, most deaths occurring in Africa. Effective control of malaria will require a combination of interventions. These include: improved treatment including effective self-medication, wide use of impregnated bednets, vector control using methods shown to be cost-effective and acceptable, and development of a malaria vaccine.
At the start of the 21st century there will be over 200 million malnourished children in the world.5 Two thirds of them will live in Asia. Malnutrition underlies a high proportion, more than half, of all childhood deaths. Malnutrition and infectious diseases are linked in a vicious cycle, often a downward spiral toward death.
Protein energy malnutrition, resulting from diets that are grossly inadequate in quantity and quality, is the most visible form of malnutrition, leading to stunting or wasting. But also of great importance are widespread deficiencies in micronutrients including iron, vitamin A, iodine and zinc. Iodine deficiency, in fact, is a major concern in Asia 48% of the world's total goitre population are in Asia. Furthermore 58% of the world's population living at risk of iodine deficiency disorders are in Asia. Recognizing this, WHO has set a target to virtually eliminate iodine deficiency disorders by the year 2000. It must be emphasized, however, that continuous control efforts will still be needed in the next century.
Furthermore, no government can claim to be doing all it can to improve child nutrition if it allows practices that undermine breastfeeding such as the aggressive marketing of breastmilk substitutes. Breastfeeding is certainly the most widely available, and arguably the most powerful prevention against both malnutrition and infectious diseases as well as being highly beneficial to healthy psychosocial development.
Child health programmes must work to ensure that exclusive Breastfeeding becomes the norm for the first four to six months of life and that Breastfeeding is protected and supported up to 2 years of age and beyond. Achieving this requires mother- and baby-friendly health services, effective counselling for pregnant women and mothers, arrangements to facilitate Breastfeeding by working mothers, and measures to ensure that Breastfeeding is not undermined by commercial practices. It is also important that commercial practices do not undermine the promotion of nutritious complementary foods made from locally available materials.
In situations of high HIV prevalence counselling should be provided in a factual and balanced way that does not unnecessarily scare mothers away from breastfeeding.
Measurable malnutrition is only one part of the spectrum. In some populations, including in developed countries, while there may be few families with visibly malnourished children there are many that go to bed hungry at night. One aspect of families coping with inadequate resources for food is to change the diet, maintaining quantity at the expense of quality. (Fig. 5)6 gives examples of dietary changes in the face of scarce resources. The resultant childhood diets may not result in measurable malnutrition but may have serious health consequences later in life: cardiovascular disease and diabetes being just a few examples. Child health authorities must turn their attention to hunger, and not only malnutrition, in vulnerable populations.
Perinatal and Neonatal Mortality, and Hereditary Disease
Despite improvements in childhood and infant mortality rates in recent decades, those for fetal death and death in early infancy have proven resistant to health interventions. WHO estimates that in 1995, 39 of each 1000 live births in developing countries died before reaching one month of age. In Africa, the figure was 75 per 1000 while in Asia, as a whole, the rate was 53 per 1000, still six times higher than in North America. Particularly striking in the Asian continent is the high rate of perinatal deaths, 41 per 1000 births (fig. 6).7
One of the factors underlying these high rates is low birth weight. It was estimated that in 1990 one-sixth of all children were born underweight, the highest rates being iii Asia, where 21% of newborns had a low birth weight (fig. 7).
Perinatal and neonatal death rates can only be reduced by implementing the interventions of the WHO "Mother and Baby package" in the following areas: family planning, antenatal care, clean, safe delivery, and essential obstetric care. Improvement of women's health, including but not only their reproductive health is critical to the improvement of child health. This must start in childhood and include attention to the needs of adolescent girls.
As infant deaths from malnutrition and infection decrease, genetic disorders will emerge as a major residual cause of infant mortality and morbidity and will become a health priority in the 21st century. About 5% of children are born every year with some congenital or hereditary disorder, including 300 000 with haemoglobin disorders. Thalassaemia is one of the most prevalent genetic diseases in at least 10 Asian countries representing a population of some 400 million. Advances in genetic technology may eventually allow us to control or predict this and other conditions associated with later life, such as coronary heart disease, hypertension, and cancer.
One disease which has its major consequences in adult life but must be addressed in childhood is hepatitis B. Fortunately, an effective vaccine against the viral agent is available. This vaccine has, so far, been included in immunization programmes in 86 countries world-wide, including most Asian countries. The more recently discovered hepatitis C is also an important cause of liver disease but, as yet, no vaccine exists.
Globally, there are over 350 million chronic carriers of hepatitis B, and each year it causes more than 1 million deaths. Child-to-child and mother-to-child transmission account for the majority of infections and carriers. In Asia, mother-to-child transmission at birth is especially important. Up to 95% of perinatally infected children will become chronic carriers and 25% of these will die of primary liver cancer or cirrhosis.
Child Modality and HIV/AIDS
One infectious agent and its associated disease will inevitably increase their share of child morbidity and mortality in the coming decades: HIV/AIDS. In 1996, UNAIDS estimated that I million children around the world were infected with HIV, and that another 1.3 million had already died of AIDS. It was further estimated that in 1995, 300 000 children died of AIDS and that 500000 H1V-infected children were born.8
While to date the continent with the highest proportion of childhood HIV/AIDS cases has been Africa, the incidence rates are rising with alarming speed in Asia. WHO and UNAIDS project that by the year 2000, there will have been approximately 630000 childhood HIV infections in Asia. However, it is difficult to make a long-term projection of the number of children with H1V/AIDS in the 21st century in view of the recent developments in multi-drug therapy and the effectiveness of interventions to prevent the vertical transmission of this disease.
There are no estimates of the number of AIDS orphans in Asia, however, in 1991 the WHO Global Programme on AIDS estimated that there would be 10 million AIDS orphans worldwide by the year 2000. During the first years of the epidemic in any particular country, there are relatively few AIDS orphans, due to the relatively few adult deaths in the early stages of the epidemic. A study carried out by the Orphan Project (New York), estimated, however, that in Thailand there were between 15 000 and 30 000 orphans already by the year 1995, and projected that there will be up to 100 000 by the year 2000.
Children cannot be allowed to grow up to expose themselves to risk through ignorance. Health education related to HIV/AIDS must start early enough in life to be effective when sexual activity starts.
Consequences of Urbanisation and Changing Lifestyles
Globally there is a trend towards urbanisation. By 2000, 47% of the world's population will be urban dwellers compared with 34% in 1960. This trend is most marked in the least developed countries. In the year 2000, there are expected to be 24 cities in the world with a population of 10 million or more. Twelve of them will be in Asia (fig. 8).9
Urbanisation brings with it increased exposure to determinants of health not so prevalent in rural settings. These include overcrowding, air pollution, violence, and road traffic. Often urban life may mean unsatisfactory living conditions and unemployment. These increase stress in families leading to a higher incidence of psychosocial problems. These are not restricted to adults. The incidence of mental illness among children is increasing. One symptom of this is rising adolescent suicide rates.
Globalization of the world's economy, including the globalization of communication networks, has brought marketing to most corners of the world. Regrettably this trend is far more likely to expose individuals, including children, to advertising for products detrimental to health, for example tobacco and alcohol, than to health-promoting messages and examples. In addition to these legally marketed substances, illegal drugs are becoming more widely available. A combination of economic precarity, psychological stress and urban promiscuity ensure both the availability of, and a market for, illegal drugs. While attention is often given to their source in various developing countries insufficient attention is given to the reasons underlying and allowing their consumption. Drugs are a menace to the health of children and young people that must be addressed with honesty and vigour.
All of these problems require multifaceted interventions. Reducing the risk for children of road traffic, for example, requires improved roads and road rules, better driving standards through driver education, and legislation and education on seat belts and bicycle helmets. In Oregon, USA legislation making compulsory the wearing of bicycle helmets has been associated with a doubling of their use. Use while commuting to school rose from 20% to 56%.
Special attention must be given to the question of smoking. Every 10 seconds another person dies as a result of tobacco use. 100 to 150 million of today's children will eventually die of smoking-related disease if current trends are allowed to continue.10 Rates of increase in tobacco related disease are expected to be particularly high in Asia. By 2020 as much as 16% of the total disease burden in China may be due to tobacco.
Most adult smokers started smoking before the age of 18. It is clear to the tobacco industry where marketing can be most effectively targeted. It must be clear also to public health authorities. If tobacco related disease is to be curbed children cannot grow up in a world where smoking is socially acceptable, where cigarettes are one of the world's most heavily promoted consumer products, where cigarette packets bear benign or no warnings, and where cigarettes are readily available to children.
But interventions to reduce smoking do work. In Canada in 1979, 46% of 15-19 year olds smoked. In 1994, after wide changes in policy and intensive health education, the percentage was 29%.11
Another consequence of lifestyles, including changing diets, can also be obesity. There is evidence that this is a growing problem in better-off and middle-income countries.
Even in children, obesity is associated with hyperlipoidemia, hypertension, non-insulin dependent diabetes mellitus and fatty liver, which are called "adult degenerative disease". Many studies have demonstrated abnormalities of serum lipids among school-age children.12
Cardiovascular disease is emerging rapidly as a major public health concern in developing countries, especially in Asia. There is convincing evidence that the processes leading to cardiovascular diseases such as coronary heart disease and hypertension start in childhood and are directly linked to lifestyle, such as eating patterns, smoking, and exercise habits.
To summarize, good diet is crucial to health. Diets and eating habits are often established in childhood. Health promotion programmes must recognize and address this issue.
As has been stated, in countries where communicable diseases are progressively brought more under control, the relative importance of non-communicable diseases will increase. To take one example, bronchial asthma is a non-communicable disease of importance on a global scale. The prevalence of bronchial asthma has increased markedly in industrialized countries in the past 40 years. There is much variability between countries, but in the worst affected countries 40% of children show some signs of asthma and a small but significant proportion of these will be severely disabled or die as a result of the condition.
In many parts of the developing world, particularly the cities in Asia and Latin America, paediatricians report an increasing prevalence of asthma. Research is urgently needed to adequately document this problem and identify interventions which might allow developing countries to avoid following the same path as the industrialized countries.
Child Abuse, Neglect, Violence and in Armed Conflict
This long but not exhaustive list of issues about child health must contain some reference to child abuse, neglect, violence and armed conflict. Child abuse has been a societal phenomenon for centuries. However the magnitude of the problem is only now beginning to be understood. Child abuse and neglect includes four distinct condition: neglect: physical violence, emotional abuse and sexual abuse.
Child abuse is found in all societies and in almost always a highly guarded secret, wherever it take place. In countries with reliable mortality reporting, WHO estimates that as many as one in 5,000 to one in 10,000 children under the age of five dies each year from physical violence, In the same countries, from one in 1,000 to one in 180 children are either brought to a health care facility or are reported to child welfare services as a consequence of abuse every year, although much lower rates are also noted. According to interview of children or young adults in Finland, the Republic of Korea and USA, from 5 to 10 percent of all children experience physical violence during childhood. Physical violence and sexual abuse in the home is a factor contributing to the phenomenon of "street children" in both developed and developing countries, particularly in the mega-city. Further abuse on the street is an everyday reality, and child prostitution is one of the way of ensuring sufficient income for survival.
Children in armed conflict is another issue of concern today, and it may continue to the next century if the long lasting peace cannot be bring to the world. Our children are growing up in a world where military expenditure claims almost twice as much of the public funds as expenditure on health. It is a world where there are 7 times as many military personnel as doctors and nurses combined. More and more frequently children are exposed to armed conflict.
In Mozambique almost half a million children perished in the 8 year war in the 1980s, and at least 10 000 boy soldiers were recruited.13 In Angola, 36% of children have accompanied soldiers into war. Between 10 and 20 million land mines remain to be cleared in that country alone. Their victims are often children at play. The country has an estimated 10 000 children with one or more amputated limbs. And if these examples are comfortably far away, there are others in Asia, such as Afghanistan and Cambodia. These risks to child health can be diminished. A ban on anti-personnel mines would make the world safer for future generations of children.
Research on Child Health
Today the vast majority of research on child health problems, even those of the developing world, is funded by industrialized countries. As Asia becomes increasingly more affluent it should assume a greater responsibility for stimulating and supporting health research related to the needs of its population, including the poorest sectors. Research should not simply mimic that being conducted in industrialized countries but should be adapted to the regional needs. Such research could include the epidemiology of childhood diseases in Asia, operational research and health system research to improve the effectiveness of child health care, social and behavioural research (for example on reducing the use of tobacco, alcohol and other addictive substances through interventions aimed at young people), and biomedical research targeted towards the prevention and control of the major killers of children.
Addressing all of the health problems mentioned requires a functioning health system. All over the world health systems are under reform, in some cases replacing existing systems with approaches that are unproven or have even failed in other countries. Among the issues that must be addressed are priority setting for public spending, health financing mechanisms, and the roles of private and public sectors.
These issues are challenging for countries with a long tradition of established decentralized health policies and controls. They are even more challenging for countries moving rapidly from centralized control to rapidly liberalizing market economies, including in the health sector.
It should be clear from this article that improving child health in the 21st century, as now, will require changes across a broad spectrum of sectors and areas ranging from international politics to macroeconomics, to health biomedical interventions. Priority setting will be complex.
Before concluding, however, that the task is too daunting it must be remembered that just 5 conditions, all preventable or treatable, are the direct cause of 55% of all childhood mortality. And this sad state is likely to persist in 2020, unless something changes now.
Addressing the major killers of children is a high priority for WHO. Along with UNICEF an approach has been developed which brings together most of the essential curative and preventive interventions needed. This approach goes by the name of Integrated Management of Childhood Illness (IMCI) (fig. 9) and it is being adopted by more and more countries in an attempt to make priority child health services more effective and efficient.
This approach is simple and affordable and yet many children of the developing world are deprived of its lifesaving potential. Surely, addressing this inequity is one of the highest of global child health priorities, now, and as we enter the next century.
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2. Sazawal S, Black RE. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lancet 1992:340:598-53.
3. World Health Organization. Water Supply and Sanitation Collaborative Council, UNICEF. Water Supply and Sanitation Sector Monitoring Report 1996. WHO/EOS/96.15.
4. World Health Organization, Global Programme for Vaccines and Immunization, Expanded Programme on Immunization.
5. World Health Organization, Division of Nutrition.
6. Kendall A, Olson CM, Frongillo EA Jr. Relationship of hunger and food insecurity to food availability and consumption. J Am Diet Assoc 1996;96:1019-24.
7. World Health Organization, Division of Family and Reproductive Health, Maternal Health and Safe Motherhood Programme. Perinatal Mortality, WHO/FRH/MSM/96.7.
8. UNAIDS and WHO, July 1996.
9. UNDP Human Development Report 1996.
10. World Health Organization, Tobacco Alert, May 1995.
11. A critical review of Canadian survey data on tobacco use, attitudes and knowledge.
12. Yamashiro Y. Adult degenerative disease in children: prevention and treatment of obesity in children from Japanese experiences. Department of Paediatrics, Juntendo University School of Medicine, Tokyo, Japan.
13. Bass D. Red Cross Children's Hospital, Cape Town. Personal communication September 1996.
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