~ui %i organisation mondiale de sant~

W O R L D H E A L T H ~ U I -1 %I ORGANISATION MONDIALE ORGANIZATION DE LA S A N T ~

REGIONAL OFFICE FOR THE BUREAU REGIONAL DE LA EASTERN MEDITERRANEAN MEDITERRANEE ORIENTALE

R L G I O I J E L COFI'IITTEE FOR TIl& EASTT, RI.J ?II:DITER?J\NE:AN

Twenty-eiqhth Session

Agenda item 13

Ell/~C28/Tech.~isc.l/Add.l

September 1378

ORIGINAL: ENGLISI1

TECIINTCAL DTSCUSSIQNS

T h e Presept State of Child H e a l t h in the Region

PROPOSAL CONCERNING A POSSIDLL

VOLUNTARY FUND FOR CI I ILD HEALTH

f o r t h e

F:ASTEHN PSEDITERRANEAN 9EGION OF TIIE;

IJQRZD IiEPLTH ORGAN1 Z A T I O N

TABLE OF CONTENTS

I INTRODUCTION

11. J U S T I F I C A T T O i I OF A VOLUNTARY F U N D FOR C H I L D IIE;ILTh FOR THE RE(;ION

IIT O?:.JI<CTIVES 'OF .A 'JOT,I!NTAKY FljNI) FOR CHILD tIEr^\LTli

I V ACTIVITIES AND BUDGET

I n t i l e l ' ec r i l i i ca l 1 ) i s c u s s i o n paiJcr t l i c ~ n a t u r e i111d tilt ' m a n n i t u d e o i t i l e roble lens

o f c h i 1 d heal t i 1 i n t h e Ke::ion a r e d r > s c r i b c t l , 'The e x c e s s i v e amount o f r ~ r c v ~ ~ r l t ~ ~ l ~ l t

i l l n e s s , ~ f f c c , t i q : i n ! . a n t s and v e r y youn? c i i i l d r e n anrl t i l e v e r v hi : -h . i t . n t n rn t i - s

u n d c r t h e ng;e o i t h r e e ycxcjrs I:ave b e e n i ~ l t l n t i f i c d a s t h e m o s t s e r i o u s p r o b l e m and

o f t n c h i z h e s t p r i o r i t y i n t h e l i g h t o i t h e commitments of t h e Member S t a t e s , t o

t i l e p e o p l e o t t h e i r c o u n t r i e s , i n r e s p e c t of t i l e r!, l ) c . c ? a r a t i o n o f Lhe RL ; l ~ t s o f

t h o C h i l d , t h e lJ110 C o n s t i t u t i o n nnd r e c e n t r e s o l u t inn . : o f t h e 1:orld I leal t h A s s c n b l y . The L n t e r n a t i o n a l T r a r o f t h c C h i l d ( L Y C ) b c c l n l s a v e r y n p p r o p r i a t e t i m e t o r,..iht, r

c o n c e r t e d a t t a c k o n t h e s c p r o h l ~ s m s ui c l ~ i l d h e a l t h i n t h e way wti ich i s d e s c r i b e d

s p e c i f i c a l l y i n s e c t i o n 5 o f t h e T c c h n i c ~ ~ l U i s c u s s i o n , a n d w h i c h i s s u ~ u n a r i z c t l i n

T a b l e 4 , ; ) a s e s 23-29, of t l i e p a p e r .

IT JUSTTFIC.ATI0'; OF ,I VOLlJNTAKY FCNI) FOR CIIILT) HEALTII 1:OK TIlE RECIO!:

I f !;I10 i n t h i s lie::ion i s t o i n c r c . a s t b s \ l b s t a n t i n l l y i t s c o l l a b o r a t i o n w i t t ~ t h e

!lemher C o u n t r i e s i r ~ t h e k i n d o f a c t i v i t i e s and p r o y , r a r m e s i n c h i l d h e a l t h d e s c r i b e d

a s l i k e l y t o make a n i : ! ipact i n r e d u c i n ; i n f a n t and yorin:: c h i l d n o r t a l i t y , t h e n i n -

c r e a s e d r e s o u r c e s o f -nanpowt,r and finances n e e d t o b e d e p l o y e d by WHO i n t i ~ i s s u b j e c t

a r e a . T h i s i n d e e d i s h c i n z d o n e t o some e x t e n t a1 r e a d y . Some o f t h e exist in^ v o l u n t a r y f u n d s a r e a l r e a d y b e i n g u s e d f o r Expanded Programmes o f I m m u n i z a t i o n i n a

n ~ ~ m b e r o f c o u n t r i e s . : l o r e o v e r , t h e r e i s some i n c r e a s e d e m p h a s i s o n c h i l d h e a l t h

i n t h e WHO K c ~ u l n r P,udtrct , a s m e n t i o n e d i n t h i s y e a r ' s Annual R e p o r t . N e v e r t h e l e s s

more f u n d s th , tn w e a t p r e s e n t h a v e a c c e s s t o a r e r e q u i r e d i f 13710 i s t o u n d e r t a k e

t h e i n t e n s i f i e d p r o n r a m e o f r e s e a r c h , t r a i n i n g a n d s u p p o r t t o s e r v i c e s f o r c h i l d

h e a l t h o r i t l i n e d b e l o w , a n d i f \\TI0 i s t o d c t a s a c a t a l y s t a n d a c h a n n e l f o r i n c r e a s e d

t e c h i ~ i c a l c o l l a b o r a t i o n b e t w e e n t h e ?lembrr S t a t e s i n c h i l d h e a l t h . I t s h o u l d b e

u n d e r s t o o d t h a t w h e r e a s t e c h n i c a l s u p p o r t w o u l d h e a v a i l a b l e f o r child h e a l t h a c t l v l -

t i e s i n a l l Memher S t a t e s , a n d r e s e a r c h a n d t r a i n i n [ ; p ronrammes would s e r v e a l l

S t a t e ? , s u p p o r t which takes t h e form of supplies or equipment or of local c o s t s

w o u l d a l m o s t a l l p,o t o t h e c o u n t r i e s w h i c h have low p e r c a p i t a h e a l t h b u d g e t s , and

e s p e c i n l l y t o t h e s i x w i t h t h e l o w e s t p e r c a p i t a (;:il'.

I T T OH.II;(:'TIV!:S O Y .F\ VOLIJN'TAKY F U N I ) I'OK CI!ILT) liIl,\I,TII

To f d ~ i l i t ~ i t ~ i n c r e a s e d c o l l a b o r a t i o n b e t w e e n '310 and i t s ? \ e m b e r S t a t e s i n t h e

t a s t c r n Yi,tli t e r r t i i e , i n I t e c ~ i o n i n q p e c i . l l e f f o r t s t o l o w e r s i j : n i f i c n n t l v t h e l e v c , l of

in fan^ niid e a r l y c r l i l d h n o d n i o r t a l i t y ,

i l e t a i l e d 0 1 ) j e c t i v e s Is

1. To f i n a n c e new c o u n t r y and i n t e r c o ~ l n t r y p r o j e c t s a n d a c t i v i t i e s i n r e s p e c t o f :

1.1 I ' r c v t > n t i o n niid t r e a t m e n t of d e h y d r a t i o n i n a c u t e d i a r r h o e a ( r e s e a r c h , t r a i n i n g ,

s u p p o r t t o s c r v i c r s ) .

1 .L l ' romot i o n and p r o t e c t i o i l o f b r e a s t - f e c ~ l i n r : ( r e s e a r c h , t r a i n i n g , s u n p o r t a n d

e v a l 11'1 ti011 o f p ro i : lo t io i ia l cnmpai t .ns ) . 1 . Improvement of weanin, : d i e t s bv b e t t e r u s e o f commonly a v a i l a b l e f o o d s ( r e s e a r c h ,

t r a i n i n v ) . 1 .L 'I'c,ciini c n l s u p p o r t f o r t t i c k:xpanded I'ro(:rarnne o f I m m u n i z a t i o n (njana:,ement t r a i n -

i n : , p r o 7 r J m m c ;)lnnnin:: 2nd evaluation),

1 . > 1mj)rovt~tl t r e a t m e n t ant1 s e c o n d a r y i>revcant iou of s e v e r e o r m o d e r a t e l y s e v e r e

p r o t c i n - e n e r y ;?a1 n t ~ t r i t i o n ( r e s e a r c h / r v n l u;l t i o n o f o u t - p a t i e n t t r e a t m e n t , f o l l o w e d

by t r a i n i n : ; ) .

1 . h ,In i n n n v a t i v c t r a i n i n * : pro!;ranane f o r p r i m a r y c h i l d h e a l t h c a r e ( t r a i n i n g a n d

f o l l n \ ~ - l l p ) . 2. 'l'u I ~ r o v i d t . ;I cc71it in::cilc.y furid f o r :

2.1 1tii. t1cvelolr:nent o l m a t e r n a l a n d c l i i l t l t i ca l t l i a s p e c t s o f p r i m a r y h e a l t h c a r e p r o -

y ravu~i rs ( t i ~ c i ~ n i c n l y u r > p o r t nntf rxcl~an!:c o f e x p e r i e n c e - a l l c o u n t r i e s ; m a t e r i a l s u p p o r t

t o low-income c o u n t r i e s ) .

2.2 D i r e c t a s s i s t a r i c e t o a n y r h i l t i h e a l t h pronramrnas i n low-income c o u n t r i e s w h i c h

seen1 l i k e l y t o makc> a n i i i ~ p n c t o n yorrn,; c h i l d m o r t a l i t y b u t a r e b a d l y i n n e e d o f ma-

t e r i a l and manpower s u p p o r t .

\ c t i v i t i e s r r l n t c a t o a e t n i l e d o b j e r t i v c s o h o v c

1.1 P r e v e n t i o n and t r o a t q r n t o f dchy- d r a t i o n i n a c u t e d i ' l r r h o e n

t ' tssc~arc h

T ~ a ~ n i n g

S u n p o r t t o s p r v i c c s

1 .Z l J r o l q n t l o n and . i r o t c c t l o n of b r c a s t - f t , ~ d i n r

Research

, r.1 i n i n ,

S r l n p o r t to s e r v i t e s

1 . 3 Tn;>rovenrrnt u t w e a n l n d i c . 1 ~

Research i n s i x c o u n t r i e s

T r n i n i n , ;lnd n u t r i t i o n cduc-<lt i n n

1.4 T e c h n i c a l s u n n o r t t \> 1 xp, lnded I'ro-ram- q e s of I m n u n i z a t i o n

Pro , , rnmc i > l i n n i n , ' and c v a l r ~ n t I o n

1 P I man'~g;er~ont t r a i n i n ? c o t l r s e s

1 .5 1mi)rovetl t r e n t r n c r l t anti s e c o n d a r y n r e - v e n t i o n o f s e v e r e n r t r t c i n - e n e r y v ~ n d l n u t r l t i o n

Opcrn t i n n a l r e s ~ a r c 1 1

T r a i n i n ?

1.6 Training pronrnmrnc for primary c h i l d

h e a l t h c a r e , r c q u i r e m c n t s f o r 1979- 1 9 8 4

t\c tu~il t r n i n i n - proqranirrlr ( i n c l u d i n ~ : ~~~3 t e l l o w s t i i s )

Fol low-rip n c t i v i t i e s

b ~ ~ r l u s r t ~ c ~ u i r e d t o r t t ~ c five,

y e a r s 1 9 7 9 ~ L I 1 9 8 7 (CS

11moun t s

h 1 5 no0

710 000

5 6 0 000

350 0 0 0

1 2 0 0 0 0

5 1 5 0 0 0

180 0 0 0

1 30 0 0 0

h00 000

300 0 0 0

3 5 0 000

150 0 0 0

1 1 8 0 000

1 5 0 0 0 0

d o l l a r s )

S u h - t o t a l 4

1 385 0 0 0

1 3 3 0 000

1~:~ /R~2Y/ ' e r t1 .~ ) i sc - . l / l ' d i i . I p a g e 4

A c t i v j t i e s r c l a t c d t o d e t a i l e d o b j e c t i v e s a b o v e

2. 1 S i ~ p p o r t f o r t l evc lnpment o f ' ICH a s ? c c t s o t n r i r n a r v h e a l t h r a re p r o g r a m n e s

T e c h n i c a l and : n , l t e r i a l s u p n o r t six c o u n t r i e s

T e c h n i c n l s r i n l m r t on1 y , f ivc m o r e t o u n t r i e s

2 .7 C o n t i n :ency and deve lopnlenq fund for d i r e c t srl?port t o any c h i l d h e a l t h I)rogr , l luncs i n low-income c o u n t r i c s

'Interi.11 and m~ipower stlppcrrt

S u h - t u t a l for nhove activiries

Addi t i o n ~ l i : , rrr -c .ount ry s t a f f ( c o n s u l t a n t s o r r ~ ; ; u l s r ) t o i n p l e n e n t these pro:rammes

( ; r n n d t o t a l f o r f i v e v e n r s

I 'unds required f o r t l i e f i v e y e a r s 1973 t o 1 9 8 3

(US d o l l a r s )

?d~lour~ t s

1 5 0 0 000

5UO 000

-

bub- to t a l s

2 txw) ooo

1 800 000

9 2 0 0 000

600 000

9 800 000

W O R L D H E A L T H ~JLJI *I ORGANISATION MONDIALE ORGANIZATION DE LA S A N T ~

, REGIONAL OFFICE FOR THE BUREAU REGIONAL DE LA EASTERN MEDlTERRANEAN MEDITERRANEE ORIENTALE

FUGIONAL COMMITTEE FOR THE LAST E R L ~ ILDITERRANEAN

Twenty-eighth Session

Agenda item 13

TECHNICAL DISCUSSIONS

EM/RC28/Tech.Disc.l July 1976

ORIGINAL: ENGLISH

THE PRESENT STATE OF CHILD HEALTH IN THE REGION

1. ISTKODUCTION

TABLE OF CONTENTS

Page

1

1.1 The commitments of t he Member Count r ies and the Organiza t ion 1 1,2 The v i t a l s t a t i s t i c s 2

L. CHILD hEALTH I N THE REGION 4

2.1 The developmental s t a g e s and t h e i r r e l a t i o n s h i p t o c h i l d h e a l t h 5 2.2 The presen t s t a t e of c h i l d h e a l t h i n t he Region a t success ive ages 6

3 . TWITIONAL ATTITUDES AND PRACTICES AFFECTING THE HEALTH OF CHILDREN 11

4. PSYCHOSOCIAL DEVELOPMENT OF THE CHILD AND MENTAL HEALTH PROBLEMS 13

5. PRIORITIES FOR ACTION TO IMPROVE C H I L D HEALTH 1 4

5.1 A c t i v i t i e s d i r e c t e d t o t h e c h i l d and the fami ly 15 5.2 A c t i v i t i e s d i r e c t e d t o t he conmunity 2 0 5 . 3 Some thoughts on materna l h e a l t h and i t s r e l a t i o n t o c h i l d h e a l t h 23

6. CONCLUSION 2 3

REFERENCES 34

1. IBTEODUCTION

" A l Z creatures ctre t he chi ldren o f God and most beZove-7

nf ,?i~ i s he t ~ h o does most good t o His chiZr'Jlen "

A Saying of the Prophet Pluhanmad

1.1 The commitments of the Member Countries and the Organization

The Declaration of the Rights of the Child adopted unanimously by the General

Assembly of the [Jnited Nations on 20 November 1959 states in Principle h that:

" . . * - * * * The child shall be entitled to grow and develop in health. To this end

special care and protection shall be provided both to him and his mother * * * * * * * *

The child shall have the right to adequate nutrition, housing, recreation and me-

dical services".

The Constitution of the World Health Organization states that one of the func-

tions of the Organization shall be to promote maternal and child health and welfare.

The General Assembly of the United ati ions (A/RES/31/169) in February 1977

proclaimed the year 1979 the International Year of the Child, with the objectives

of providing a framework for advocacy on behalf of children and for enhancing aware-

ness of the special needs of children; and to promote recognition that programmes

for children should be an integral part of social and economic development plans

with a view to achieving sustained activities for the benefit of children at nation-

al and international level.

In the same resolution the General Assembly urged governments to expand their

efforts to provide lasting improvements in the wellbeing of their children with

special attention to those in the most vulnerable groups.

The 31st World Health Assembly, in May 1978, adopted resolution 31.55, from

which the following is quoted:

"The Thirty-first World Health Assembly, ...... Considering that 1979 has been declared '~nternational Year of the child' . . . URGES Member States to give high priority to maternal and child health . . .

and ...... to co-operate with one another and with WHO in the promotion of the health of mothers and childrenl

....... requests the Director-General ........ to promote, through the regional comittee~meetings of experts from their

Member Count r ies t o c o l l a b o r a t e i n t he planning and e v a l u a t i o n of maternal

and c h i l d we l f a r e programmes,

....... and t o adv i se on t he adopt ion of measures f o r developing and inproving

them,

. . . . . . t o p r e sen t t o t h e Thirty-second World Heal th Assembly on t he occas ion

of t he I n t e r n a t i o n a l Year of t h e Child in format ion on t h e p r e sen t s t a t u s of

maternal and c h i l d h e a l t h i n t he world, a s wel l a s on t rends i n development

of r e l e v a n t se rv ices" ,

The s e l e c t i o n of " the p r e sen t s t a t e of c h i l d h e a l t h i n t he R5gion1' a s the sub j ec t

of the Technical Discussions of t h i s yea r i s c l e a r l y d i r e c t l y r e l a t e d t o t h e above

commitments.

1.2 Tlie v i t a l s t a t i s t i c s

"Tim s h o r t n space of time they s k e

That are so wondrous soset and fair"

(Seventeenth-century Engl i sh p o e t ) .

It can be s a i d t h a t important achievements i n socio-economic development have

been made i n t he R e ~ i o n s i n c e t he c r e a t i o n of t h e United Nations, and t h e r e has been

~ n a n i f e s t p rogress i n s t r eng then ing n a t i o n a l h e a l t h s e r v i c e s . These, wi th t he ava i l -

a b i l i t y of a n t i b i o t i c s , have brought about i n most c o u n t r i e s some marked improvements

i n the h e a l t h of young c h i l d r e n , p a r t i c u l a r l y perhaps i n t h e decade of t he nineteen-

f i f t i e s . I n t he coun t r i e s which r e p r e s e n t t h e bulk of t he popula t ion of t he Region,

however, a s i n o t h e r p a r t s of t h e developin3 world, no major breakthrough has been

achieved over t he p a s t decade i n t h e e f f o r t t o narrow app rec i ab ly t he wide gap be t -

ween t he i n f a n t and e a r l y childhood m o r t a l i t y r a t e s ob t a in ing i n t he se c o u n t r i e s and

those o b t a i n i n g i n Europe and North America. Only Egypt ha s d a t a going back more

than f i f t y years1, and F igures 1 and 2 i l l u s t r a t e t he se po in ts .

The popula t ion of t he 23 c o u n t r i e s of t he Region i s e s t ima ted t o be around 240

mi l l i on . They vary g r e a t l y i n s i z e and popula t ion (200 000 t o 73 000 000) and i n

t h e i r l e v e l s of socio-economic development. I n four c o u n t r i e s i n f a n t m o r t a l i t y

r a t e s a r e below 50 p e r 1 000 l i v e b i r t h s ; i n seven, between 50 and 100; and, i n

twelve, between 100 and 200. Crude b i r t h r a t e s a r e between 30 and 50 pe r I 000,

crude dea th r a t e s between 1 0 and 20 per 1 000, and l i f e expectancy a t b i r t h from 30

t o 50 yea r s , i n many c l o s e r t o 50 years2.

Children under five years constitute approximately 20 per cent of the population

of the Region, and up to 15 years about 45 per cent. Their mothers represent another

5 to 10 per cent. Ilowever, children under five account usually for over one-third of

all deaths, in 14 countries for 40 to 50 per cent. These data are illustrated in

Table 1.

In 1976 about 11 million children were born in the Region, of whom about 20 per

cent will not reach the age of five years. Half of the children in the Region are

inadequately nourished, and between 1 and 5 per cent are estimated to suffer from

such severe malnutrition as to seriously threaten their life or impair their health

if they survive. In absolute numbers, of the approximately 11 million children born

in the Region each year, about 1.5 million die in infancy and a further half million

before the age of five years, a total of two million. The great majority of these

deaths occur before the age of three years; the immediate or underlying causes are

gastro-intestinal infections, respiratory infections and the six immunizable diseases,

often combined with malnutrition.

In countries where the vicious cycle of infectious diseases and malnutrition is

prevalent, the lives of many young children consist of a series of acute illnesses

superimposed on a chronic state of ill-health with the continuous threat of a fatal

issue. Figure 3 illustrates the acute illnesses imposed in the first three years of

life on a child in Santa Maria Cauqud, a village in Guatemala, under health condi-

tions similar to those of many countries in the Eastern Mediterranean ~ e ~ i o n ~ . In

this village, in 45 cohort children observed from birth to three years, gastro-

intestinal diseases accounted for 43 per cent of all illnesses, respiratory diseases

for 35 per cent (a high figure probably typical of high-altitude regions), and common

conununicable diseases of childhood for 5 per cent.

In our own Region not only are mortality rates similar to, or even higher than,

those of Latin America but the pattern of illness and the prevalence of malnutrition

are similar also, as many studies have shown. One such study,distinguished for its

careful execution, was carried out by Leila Kame1 in the villages of Manshaat el

Bakhary and Saft el Laban, in Egypt. Table 2 shows the point prevalence of diarrhoea,

measles and respiratory infections in these villages. The study showed also a highly

significant relation between the prevalence of diarrhoea, especially in its recurrent

forms, and various degrees of malnutrition as judged by weight for age.

Extrapolating as best we can from available data, it can be estimated that of

the two million deaths under five years of age around 800 000,are caused by

gastro-intestinal infections, 400 000 by respiratory infections, at least 100 000 by

immunizable diseases and 50 000 by malaria, a total of 1.4 million. The others are

caused by diseases of the early neonatal period and other diseases of early childhood.

In spite of rapid population growth the availability of food is not considered

a major problem in most countries, and where availability is a problem it is usually

because of poverty. Dietary problems of young children are usually caused by igno-

rance about food items that can be used in weaning diets and in the diets of children

after the age of two or three years. Nevertheless, there are occasional periods of

scarcity, and there may also be people who live in places that are always short of

food, Food is but one indicator of the health status of the child: there are others

related to socio-economic development, namely per capita income, literacy, water sup-

ply, housing and environmental sanitation. These factors are closely related to

levels of c~ortality in infants and young children, as is illustrated in Figure 4 for

seler ted countries of the Ides tern Ilemisphere.

The persistence of these hizh figures of child mortality should not create an

impression that there is anything inevitable or hopeless about the situation. High

child mortality figures usually drop quite steeply. One such drop occurred 20 to

30 years ago. Infant mortality rates in the USA and Europe, which 60 years ago

were around 120 per 1 000 live births, dropped steep13 in the next 20 years despite

economic recession and unemployment, and are today mostly less than 20 per 1 000.

Ilibh child mortality.rates are not simply an expression of low economic status: They

are also susceptible to reduction by specific health measures.

2 . C E I L D HEALTH IN THE REGION

"Lde v'eve created you from dust, then from the moist germs

of l i f e , then from a blood cZot, then from a ZittZe Zump

of flesh shapen and unshapen, that oe might give you

proofs of Our power. And We cause that which We will t o

remain i n the womh untiZ the appointed time, then Me

bring pou forth as infants , then give you growth that ye

a t ta in your age o f fuZZ strength; and one of you dieth;

and another of you Ziveth on t o an age so abject that aZZ

h i s former knowledge is clean forgottentt.

The Holy Qur'an sura 22.5

EM/~C28/Tech.Disc. 1 page 5

2.1 The developmental stages and their relationship to child health

THE HUMAN LIFE CYCLE

PIUSE OF DEVELOPMENT TRANSITIONAL EVENT

1( Preschool age,

School entrance (or equivalent)

School age > Puberty L Attainment of

maturity

Age of reproduction

Climacteric

Senescence J \Death

The health of the new-bornchild is determined by a number of factors, namely the

hereditary antecedents of the parents and their state of health particularly that of

the mother, her age at pregnancy, the number of c h i l d r e n she has had,and the i n t e r v a l

between pregnancies. The health of the new-born is related also to the mother's own

health, particularly her nutritional status and the absence of diseases that could be

transmitted to the child during pregnancy. These factors may determine whether the

pregnancy will result in foetal loss, stillbirth, prematurity or a full-term live

birth,

The birth-weight of the full-term new-born may be within the average range or

may be low for the gestational age, but the chance of survival in the early neonatal

period is influenced by the various factors referred to above.

The infant is protected in the first s i x months of life by the passive immunity

against some diseases which the mother has acquired. Measles is a good example.

The brest-fed child receives additional protection, particularly against diarrhoea1

diseases, since protective factors such as secretory irmnunoglobulin A (s.1g.A) against

Escherichia Coli are available in human milk. Therefore, the breast-fed child up to

six months, even when born in an unfavourable environment, is reasonably well protect-

ed against infectious diseases, and the closeness with the mother favours his psycho-

social development.

At about six months of age this passive immunity disappears. Then the need for

supplementary feeding increases the risk of gastro-intestinal infections. Until

about thirty months he remains dependent on the mother for food and his mobility is

limited, but then he begins to move about and can express his own wishes for food.

Increased mobility increases the risk of infection from not only the family circle

but also the community, and, in additibn, there is a higher risk of accidents. It

is between six months and four or five years that in an unfavourable environment

the vicious circle of infection/~nalnutrition develops.

If the child survives, he emerges from this pattern at school-age with some im-

munity and adaptation, but now becomes more exposed to the disease pattern of adults,

and may acquire parasitic diseases such as schistosomiasis, ascariasis and hookworm,

or other diseases which occur in this Region such as tuberculosis, trachorna or

leishmaniasis. His potential for education and preparation for a productive life may

be hampered by such chronic illnesses, or by handicaps such as damage from earlier

poliomyelitis, or impaired vision or even blindness from trachoma or onchocerciasis,

or from keratomalacia due to severe vitamin A deficiency. The extent to which the

child emerges into adult life with a chronic disease pattern or a handicap depends

on the extent to which he has been protected or, alternatively, heavily and chronical-

ly exposed.

2.2 The present state of child health in the Region at successive ages

2,2,1 The new-born child

This paper does not discuss pregnancy wastage, but only the fate of the live-

born child. Extensive studies have shown that both birth-weight and chance of sur-

vival of the new-born are influenced by maternal factors such as age, birth order

and pregnancy intervals, as well as by socio-economic and cultural factors. The role

played by these factors was recently Shown for Iran and Lebanon in a WHO Study on Fa-

mily Formation and ~ e a l t h ~ as part of a study in five countries in the developing

world. These relationships were confirmed by investigations in Teheran and

EM/RC28/Tech.Disc.l page 7

Beirut, pregnancy intervals appeared to be the most important factors. However, "at risk" pregnancy and maternal malnutrition are also important factors in rela-

tion to low birth-weight, both those classified as resulting from premature birth

and those of full-term children with weights of below 2.5 or 2.0 kg. There is a

surprising scarcity of recent data on birth-weight distribution in the individual

countries of the Region; for instance birth-weight was not included in the recent

WHO study of infant and early childhood mortality in Afghanistan. Such data as exist

can be even misleading when they are drawn from maternity hospitals, since it is only

a better-off minority of women in this Region who are delivered of their babies in

hospitals. Clearly there is great need of field research in this subject, making use

of domiciliary midwives and birth attendants.

Low birth-weight has been shown to be strongly dependent on environmental fac-

tors. If birth-weights of new-borns in the Region are relatively lower than in USA

or Europe, improved nutritional status of women, wider spacing of pregnancies, the

discouragement of marriage at very young ages, and care of "at risk'' pregnancies,

should show, in the future, a progressively favourable influence on birth-weight and

perinatal mortality.

Tetanus neonatorum is a serious disease in this Region, as in some others.

Bytchenko et az6 estimated tetanus neonatorum mortality, in 1960, in Iran, at 290

per 100 000 live births (reported rate, 191) and in Pakistan at 1 423 per 100 000

live births. In Somalia, Aden and Birk7 in a retrospective study of child mortality

for the years 1970-1977 report that 154 of 3 655 live-born children died of tetanus

neonatorurn: a rate of 4 213 per 100 000 live births,or 16.5 per cent of tb. 932 deaths

among these children.

2.2.2 The child in the first six months of life

In this Region, as in most developing areas, the growth and the health of the

child in the early months of life are satisfactory in proportion to the degree to

which breast-feeding prevails. The pattern of breast-feeding described by Skukry 8 e t a2 for rural Egypt (Table 3) and in the WHO Afghanistan study still applies to

most rural areas of the Region. There are indications, however, that in urban areas,

especially where disposable income has increased rapidly, breast-feeding is declining

rapidly, even for very young children; the effects in the form of diarrhoea1 disease

and marasmic malnutrition have been noted in many countries, as have been described

by pellett9 for Libya, and by Petros-Rarvazian and cooklo for Iraq.

However, the breast-fed child in the first six months of life remains adequa-

tely protected against diarrhoeal diseases and most of the common conarmnicable dis-

eases of childhood, with the exception of pertussis, if the mother has had these

diseases as a child.

2.2.3 The child in the weaning period (6-30 months)

In the weaning period the combined effects of gastro-intestinal, respiratory

and other early childhood infections are such that death rates are higher than for

any other age-group below sixty years of age. The child now needs more nutrients

than breast-milk alone can supply; this combined with lack of understanding of

proper and supplementary feeding leads to the vicious circle of malnutrition and

infectious disease. ~aoll, in 1973, analyzed the results of community surveys of

weight-for-age measurements in children of less than five years in twelve countries

of the Region. Only 25 to 40 per cent of children had normal weights for age (over

90 per cent of standard weight). The number of children with mild to moderate

weight deficit was in the order of 30 to 50 per cent, representing a real public

health problem. The proportion of cases of severe malnutrition (marasmus or

kwashiorkor) ranged from 1 to 4 per cent in Lebanon, Tunisia, urban Iran, and urban

areas of Egypt. Severe malnutrition was found in more than 4 per cent in Iraq,

Jordan, Yemen Arab Republic and rural areas of Egypt and Iran, the Sudan, Democratic

Yemen and Pakistan, There was thus a direct medical care problem as well as a public

health problem. These surveys indicated furthermore the relation between malnutrition

and infectious diseases, particularly gastro-enteritis but also respiratory diseases

and measles. Publications based on hospital admissions of children with severe mal-

nutrition indicate that children are usually brought to hospital not for their nu-

tritional status but for an intercurrent disease. This indicates a lack of under-

standing of childhood malnutrition among the people, who do not seem to identify

malnutrition as easily as they do diarrhoeal disease or certain other illnesses.

Several publications have highlighted seasonal variations in malnutrition pat-

tern. A publication by samadil2 on admisoions of canes of malnutrition (both

marasmus and kwashiorkor) to the Kabul hospitals and Itao's13 report on Libya both

show the wave of malnutrition following the diarrhoeal disease season. The year-

long study in Jordan by Pharaon et at14 shows the successive effects of the diar-

rhoeal disease season followed by the respiratory disease season on the pattern of

malnutrition. Analysis of plaama-protein levels of the children showed that the

diarrhoea1 season had the most marked effect on plasma-protein levels, and that they

only regained higher levels just before the next diarrhoeal disease season began.

It is important to emphasize that, for the Region as a whole, malnutrition ma-

nifests itself more often as marasmus - the result of the interplay of lack of sufficient energy supply and infectious disease - than as kwashiorkor, due to an inade- quate supply of protein and protective nutrients combined with infections. Both

marasmus and the much less conrmon kwashiorkor sometimes manifest also signs of vita-

min A deficiency as well as aneamia to a degree which varies from country to country.

Rickets in the weanling is seen in most countries of the Region but is usually a

mild and temporary condition probably associated with lack of exposure to sunlight.

Poliomyelitis is still a disease of infancy and the weaning period in this Region,

as the 1975 review of poliomyelitis studies in Egypt by Imam and ~abib'~ shows and the

survey in Alexandria by Wahdan et confirms. The latter showed a prevalence of

2 per 1 000 of residual flaccid paralysis in school-children; 80 per cent of the in-

fections had occurred before two years of age.

In infancy and the weaning period there is a strong susceptibility to malaria,

and almost all children of that age are estimated to acquire the disease in the hyper/

holo-endemic areas of the southern Sudan, Somalia and the southern littoral of the

Arabian peninsula. Malaria has been incriminated directly or indirectly in a large

proportion of deaths under the age of three years in these areas.

Lastly, two of the diseases preventable by immunization-measles and pertussis -

have their peak incidence and greatest severity in this age-group.

2.2.4 The child from the end of weaning to school age (3-5 years)

The child of this age who has survived the dangers of the earlier periods now

takes a firmer grip on life, due to the acquisition of some immunity and the ability

to express his needs verbally and to feed himself. However, increased mobility un-

accompanied by discretion exposes him to accidents in the home and nearby. Most

cases of severe injury and deaths from accidents occur at this age. The child is

also exposed to new sources of infestation with intestinal parasites, while diseases

like diphtheria and tuberculosis which show no special association with age in child-

hood assume relatively greater importance. On the whole, however, this period is

relatively safe for the child as compared with the earlier period, and mortality

rates are much lower than in children under three years.

EM/RC28/Tech,Disc,l page 10

2.2.5 The schoolchild

This is the age group with the lowest mortality rates. Nutritional deficiency

in early childhood results usually in lower heights and/or weights in these cohorts

of children compared with international standards. To take a reasonably typical -+ :.

example of studies on the health status of schoolchildren, the comprehensive review

by Labib et a217 concerning school-age children in urban and rural parts of the

Guiza governorate in Egypt showed weights in both urban and rural boys to be below

the international standard.' The girls were closer to the standard, and urban girls

reached it by age 17 years. In regard to height-a more specific index of earlier

serious nutritional difficulties-measurements were below standard for both boys

and girls at all ages and were lower in the rural groups of both boys and girls.

said18 in his nutrition survey for WHO in Yemenz197& compared height: and weights of

school-age boys and girls with those of these Egyptian children and found all values

lower in Yemen children of both sexes.

The Egyptian study showed late signs of rickets which predominated in boys and

were much more frequent in the age group 16 to 20 years,.indicating that the children

born after 1954 had had less severe active rickets in infancy. Twenty-five cases of

residual paralysis attributable to poliomyelitis were found in the sample of roughly

4 000 children: a very high rate of 6 per 1 000. Late trachoma was rather frequent

in both boys and girls, but acute trachoma was almost twice as common in boys.

Schistosomiasis was found in both boys and girls but was considerably more frequent

in boys and girls from rural schools (urban boys 7 per cent, rural boys 53 per cent;

urban girls 1 per cent, rural girls 9 per cent).

Levels of haemoglobin showed moderate anaemia in both boys and girls. Sore

thr0a.t and enlarged tonsils were frequent, and rheumatic heart murmurs were definitely

more frequent in girls. Caries was highly prevalent, Thyroid enlargement was much

more frequent in girls, with maximum frequency at preparatory school level. Nine

per cent of male secondary schoolchildren were already smoking regularly. No girls

smoked. Intestinal parasitism was also frequent, particularly for oxyuris and

ascaris, and much higher in rural schools. 'Rie findings in regard to heights and

weights of schoolchildren in Egypt and Yemen Arab Republic give probably some pers-

pective of the result in impaired growth of different degrees of severity of mal-

nutrition in early childhood in two countries. The various disease conditions found

in these children are likely to be representative of many countries of the Region.

Eld/RC28/Tech .Disc. 1 page 11

3. TRADITIONAL ATTITUDES AND PRACTICES AFFECTING THE HEALTH OF CFIILDREM

"And when one of them receives t idings of the b i r th of

a female child ( f o r him) his face darkens i n sadness

and disappointment. He hides himself from the folk

because o f disgrace o f that whereof he has t idings.

(He argues w i t h himself) shall he keep her i n contempt

or bury her under the earth? Evil i s the ir judgement!'

The Holy Qur'an

It is generally understood that certain traditional attitudes and practices in-

fluence the health of families and their children favourably or otherwise. Some

practices that may now seem very detrimental may originally have developed with a

beneficial intention. Thus, the custom of infibulation of female children, which at

present attracts much adverse criticism, may have been motivated originally by a de-

sire to protect the nubile girl from assault in a nomad society. Discrimination in

attitude regarding the birth of a male or female child may have its initial explana-

tion in the fact that societies needed males for maintaining the name of the family

in warring societies or because of the need for farm hands, an argument still valid

in many agricultural societies today. However, to understand the origin of these

attitudes or practices is not necessarily to condone them when they are frankly bad.

The discrimination against girls, which still persists in rural areas of the Region,

even to the extent of being detectable in mortality rates and nutritional status19,

is not Islamic. On the contrary, it is strongly condemned in the Qor'an as the

above quotation shows. Fortunately, this discrimination is undoubtedly diminishing.

Traditional attitudes and practices affecting child health which need to be re-

cognized and taken into account are those related to pregnancy, lactation, childbirth,

weaning , and specific illness.

Taboos about diet during pregnancy play an important role in malnutrition of

pregnant women, and frequently contribute to maternal depletion following successive

childbirths. An example is the attitude to morning sickness, which is confused with

illness, which results in food being withdrawn during the first months of pregnancy.

One traditional practice encouraged in the Qor'an is breast-feeding ("And

mothers shall suckle the ir children for a f u l l two years, those who wish t o complete

suckling") and its benefits have been mentioned already in this paper. However,


throughout the Region there i s a reluctance to introduce foods of high n u t r i t i v e

value i n the weaning d i e t . This app l i e s p a r t i c u l a r l y t o meat, milk and eggs; they

may not be given to the ch i ld before the age of two. As a general pat tern , s o f t

foods a r e considered r i g h t f o r the ch i ld i r r e spec t ive of n u t r i t i v e value, and tough

foods not s u i t a b l e u n t i l the chi ld is older ; i t is not rea l ized t h a t tough foods

can be made pa la tab le to the chi ld .

Taboos e x i s t a l s o i n regard to i l l n e s s of children. For instance, i n measles,

food i s p r a c t i c a l l y withdrawn f o r severa l weeks and the chi ld is kept i n bed f o r 30

t o 40 days. It i s most important t h a t heal th workers should l ea rn about t r a d i t i o n a l

p rac t i ces i n the d i s t r i c t s where they work and only attempt to change those t h a t a r e

known to be harmful. The d i f f i c u l t i e s t h a t heal th workers have experienced i n changing

habi ts have much t o do with the f a c t t h a t during t h e i r t r a i n i n g they were not taughi:

t o take a to le ran t a t t i t u d e with famil ies . Sometimes heal th workers who a r e working

outs ide t h e i r own socio-cultural environment a r e not r ead i ly l i s t ened to by the people.

The present trend i n bas ic heal th services and primary heal th ca re t o u t i l i z e l o c a l l y

r ec ru i t ed hea l th workers and b i r t h a t tendants should make i t e a s i e r f o r well-motivated

workers t o convince mothers and famil ies of the advantages of a b e t t e r approach t o the

feeding of pregnant women, to persuade l a c t a t i n g women to introduce improvements i n the

weaning d i e t , and to promote a more r a t i o n a l approach to the ca re of a s i c k child.

I n t h i s respect , education f o r healthy l i v i n g i n primary and secondary schools

should r e f e r to loca l customs and taboos relaced to heal th , so t h a t fu tu re couples may

l ea rn to avoid those t h a t a r e dangerous.

Consanguineous marriage and genet ic d isorders

Every region o r e thnic group has i t s pa r t i cu la r problems with inher i t ed diseases ,

The only genet ic d isorders of public hea l th s ignif icance i n t h i s Region a r e thalassaemia

and favism, favism being much the more widespread. One t r a d i t i o n a l p rac t i ce , tha t of

f i r s t - cous in marriage, has a marked detrimental e f f e c t on ch i ld health,as Cook and

Harsl ip showed i n t h e i r study i n ~ o r d a n ~ . It i s common i n p a r t s of the Region, and

contr ibutes approximately an add i t iona l 5 per cent t o i n f a n t morta l i ty r a t e s i n the

offspring, because of the increased occurrence of almost a l l types of genetic dis-

orders, The custom is now becoming l e s s common.


4 . PSYCHOSOCIAL DEVELOPMENT OF THE C H I L D AND MENTAL HEALTH PROBLEMS

The outline of these problems was provided by ~aasher~l in a contribution to

the WHO expert committee meeting on child mental health and psychosocial develop-

ment in 1976. It also gives an overview of the efforts that countries are making

towards development of services in this field. For the sake of brevity the present

report highlights only a few areas.

The psychosocial development of the preschool child is strongly influenced by the

extended-family pattern typical of rural areas and still common in cities and towns,

where family groups, although now set up as separate entities, still retain close

relations with each other and assist each other. However, the drift of rural people

to cities is resulting in suburban slums where families live far from their relatives

in the villages, and thus lose the advantages of the extended family. Women often

work, to supplement their husbandd wages, and children cannot be cared for by grand-

parents or aunts. There is now an evident need for day-care facilities and for

institutional care for orphaned, abandoned and handicapped children. In the tra-

ditional extended-family pattern such facilities are hardly needed, since the family

takes care of all its children to the best of its ability.

In broad perspective in this Region, as in all other areas of the developing

world, there is need to stem the excessive unplanned migration from rural to urban

areas, by making village life more attractive through improved agricultural practices,

education, improved housing and basic environmental sanitation. For the cities, the

problem remains of how to develop adequate urban planning which ensures progressive

transformation of traditional patterns without loss of their essential inherent

virtues. The problem of slums brings also in its wake an increase in the communi-

cable-disease load which migrants bring with them and is greatly compounded by the

difficulties in providing adequate water supplies and sewage-disposal facilities for

these communities on the "septic fringe" of the cities.

In addition to these problems of psychosocial development and behaviour, there

are the organic mental health problems, espec'ially neuro-psychiatric problems, learn- I

ing disorders in school-age children and epilepsy. There is also the very difficult

problem of severely mentally handicapped children, often combined with a neurological

syndrome, with growing needs for their care and rehabilitation. In regard to malad-

justment and deviant behaviour, several countries of the Region are transferring

E M / R C 2 8 / T e c h . D i s c . l page 1 4

r e s p o n s i b i l i t y f o r c a r e from t h e penal system t o t he s o c i a l s e rv i ce s . The develop-

ment of s p e c i a l i z e d mental h e a l t h s e r v i c e s f o r schoolchi ldren w i l l provide f a c i l i -

t i e s f o r c h i l d r e n wi th poor school performance, psycho-neurosis, ep i l epsy and speech

d i so rde r s . A s these problems come inc reas ing ly t he f o r e coun t r i e s w i l l need t o

adopt a n a t i o n a l po l i cy on mental h e a l t h s e r v i c e s and provide t h e necessary s o c i a l -

wel fare and educa t iona l f a c i l i t i e s . ' The genera l o r i e n t a t i o n of po l i cy should be t o

keep c h i l d r e n i n t h e family by providing t h e s p e c i a l he lp they need.

5. P R I O R I T I E S FOR ACTION TO IMPROVE CI-IILD HEALTI-I

When w e review, a s we have done, the var ious problems a t t he d i f f e r e n t s t ages

of c h i l d l i f e , one problem predominates above a l l and c r i e s ou t f o r ac t i on . That

i s t h e very g r e a t number of dea ths which occur below the age of t h r e e years: c l o s e

on two m i l l i o n a yea ro The g r e a t ma jo r i t y a r e due t o preventable i n f e c t i o n s , about

ha l f of them d ia r rhoea1 d i sease , o f t e n combined wi th protein-energy malnut r i t ion .

This mainly preventable l o s s each year of almost two m i l l i o n o u t of e leven m i l l i o n

born seems t o outweigh by f a r a l l o t h e r problems and a r e a s of pos s ib l e a c t i o n f o r

c h i l d h e a l t h , such a s school hea l th , e f f o r t s t o improve t h e h e a l t h of the c h i l d a t

b i r t h , o r mental h e a l t h progralmnes, even though a l l o f t he se a r e t r u l y important

and f u l l y worthy of ac t i on . This is e s p e c i a l l y so when we r e c a l l t h a t m o r t a l i t y

i s only the v i s i b l e and dramatic man i f e s t a t i on of a g r e a t d e a l of a c u t e and chronic

m a l n u t r i t i o n and i l l n e s s , some of which i n f l i c t s permanent damage on t h e surv ivors .

There is a danger t h a t pub l i c h e a l t h programmes f a i l i f they a r e , too narrowly

focussed s i n c e t h e problems they confront have mu l t i p l e causes. They could f a i l

a l s o because they a r e too d i f f u s e , by t r y i n g t o do too many t h i n g s a t once, s o t h a t

no one problem is tackled wi th enough resources , vigour and s ing l enes s of purpose,

t o make a r e a l impact, t he danger of d i f f u s i o n of e f f o r t , i s perhaps t h e g r e a t e r ,

and we may r e c a l l a t t h i s po in t t h a t some of t h e b e s t successes of WHO'S co l labora-

t i o n wi th i t s Member Countr ies have been i n programmes whose o b j e c t i v e s were l imi t ed

and e f f o r t s concent ra ted on a s i n g l e t a r g e t o r group of t a r g e t s .

Therefore it would seem l o g i c a l , i n view of t he terms of t he WHO Cons t i t u t i on ,

t h e Rights of t h e Child, and t h e o b j e c t i v e s of t he I n t e r n a t i o n a l Year of t he Child,

t o s i n g l e o u t t h i s huge number of dea ths under t h r e e yea r s of age f o r s p e c i a l and

unremi t t ing e f f o r t i f a permanent breakthrough i s t o be made t o an a l t o g e t h e r h igher

l e v e l of c h i l d h e a l t h and wel fare . Las t ly , i f ou r l i m i t e d r e sou rces a r e t o do t h e

g r e a t e s t pos s ib l e good f o r t h e largest number of s u f f e r e r s t h i s problem should pre-

dominate over a l l o the r s .


However, the questions now arise of what can be done to reduce permanently this

disastrous loss of life and how it can be done. The remainder of this paper devotes

itself to answering the first of these questions: what can be done? How it can be

done, as far as collaboration between countries and with WHO and UNICEF goes, is

something which can be discussed now and later; and how it can be done, as far as

each ministry of health and government in general is concerned, is something for

internal discussion and decision.

What then can be done with a reasonable expectation of measurable results?

A programme to reduce mortality and raise the level of health and nutrition of

infants and children under three should comprise two kinds of activities: those which

are personal, directed to the child, the mother and the family; and those which are

public, directed to the community of which the families are the components.

5.1 Activities directed to the child and the family

5.1.1 Prevention of death from diarrhoeal disease

Bottle-fed babies in poor environmental circumstances will be in danger of diar-

rhoeal disease already in the first months of life, but both bottle- and breast-fed

infants are increasingly subject to this danger from the age of six months when sup-

plementation has to begin and the transitional diet initiated.

Children who die from diarrhoea die from dehydration, three-quarters of a million

of them each year in our Region alone. The discovery that acute gastro-intestinal

infections will respond to oral rehydration with a particular formula of electrolytes

and glucose, and thus escape toxic and often fatal dehydration, represents a break-

through of great potential importance in the fight against death from diarrhoeal dis-

ease. Early trials with oral rehydration were initiated several decades ago, but

interest was revived only with new knowledge about the physiology of sodium absorp-

tion, the development of the present formula and its success in very adverse condi-

tions in treating cholera in Bangladesh in 1971. WHO and UNICEF then produced the

formula in sachets following trials which showed considerable success in infantile

diarrhoeao

The movement to make this treatment widely available is rapidly gathering momen-

tum, In May of this year an Advisory Group to help to formulate a Diarrhoea1 Disease

Control Programme met in WHO Headquarters. This Group emphasized oral rehydration

as the most urgent and promising of the measures which could be taken in the short


term. It is the development and success of oral rehydration which has stimulated

renewed interest in diarrhoeal disease control and World Health Assembly Resolution

31 / 4 4 .

In our Region controlled trials have recently been conducted in rural and urban

areas of Egypt and in West Azerbaijan in Iran; they confirmed again that oral rehy-

dration at the village level is feasible, acceptable, and effective in preventing

dehydra.tion and reducing the referral rate, and even in improving nutritional status

for some months after the episode. It is so potent in preventing clinical or severe

dehydration that there is little doubt that its widespread use will bring about a

marked reduction in mortality. Even a 10 per cent reduction would mean 75 000 lives

a year, and one would hope for much better than that.

Thus, this measure was given also a high priority in the recent E M . Meeting on

Cholera and Diarrhoea1 Disease Control. Some of the governments of our Region have

already committed themselves to its widest possible application in infantile diarrhoea

and have taken steps to secure supplies of the formula, including local production and

packaging. Those governments that have not yet done so are recommended to give urgent

consideration to the subject as the first priority in child health at the present time.

5.1.2 The promotion and protection of breas t-f ceding

In the Region at large, in rural areas, breast-feeding is still the prevailing

pattern and continues usually up to two years. In urban areas it is in decline. Not

only is human milk relatively sterile but also in the past decade it has been shown to

contain, besides adequate nutrients, specific anti-infective properties which protect

from diarrhoeal disease, not available from cow's milk. The preservation of breast-

feeding is therefore most essential, since only in areas with high levels of sanitation

has feeding with cow's milk been shown to be safe. It is true that upper- or middle-

class educated families in developing countries can use bottle-feeding with safe pro-

cessed milk-products with a good measure of success. This is not possible for poorly-

educated families in highly insanitary environments. This form of infant diet is for

them a financial burden, leading to over-dilution of the powdered milk and malnutrition

from that reason as well as from diarrhoeal infections. Breast-feeding remains at

present a life-saving device for which there is no eafe substitute in insanitary cir-

cumstances. It will be very galling if gains made in the health of children aged six

months to three years by controlling infections, improving living conditions and general

economic development, are snatched away or greatly diminished by a sharp increase in


diarrhoea1 disease and marasmic malnutrition under the age of six months due to a

steep decline in breast-feeding.

It would be quite wrong to think that breast-feeding is a lost cause, that

nothing can be done to arrest its decline. Feeding practices, as far as the choice

between breast and bottle is concerned, are indeed susceptible to change in the

direction of breast-feeding, as is shown not only by wartime experience and by the

present considerable increase in breast-feeding in Europe, Australia and North America,

but also by an increasing number of articles in the medical journals showing how by

this or that particular action or programme the prevalence of breast-feeding by some

groups of mothers was increased substantially.

The actions likely to promote and protect breast-feeding are:

(a) to include in basic and in-service training of all doctors, nurses and other

health workers the new knowledge of the last decade about the psychology and physio-

logy of lactation, about the specific anti-infective properties of human milk, and

its many other advantages including its birth-spacing effect in the early months

after giving birth if practised exclusive of other feeding methods.

(b) to forbid public advertising of powdered milk products for bottle-feeding. The

foreign companies are anxious to make up for declining sales, following the recent

fall in birth rates in the more developed countries, by selling milk to the developing

countries. However, they do a great public disservice by their advertising by a

mechanism inherent in the psychophysiology of lactation which may be briefly expressed

thus: presence of alcernative to breast feeding 3 doubt about what to do for the

best -- anxiety- poor let-down reflex* dissatisfied baby- more anxiety* more

failure of let-down reflex -+ hungry, howling baby+ bottle feeding.

(c) to change all obstetric-ward practices which interfere with the establishment of

breast-feeding, such as separation of babies in nurseries, or the giving of glucose

water to newborns instead of encouraging innnediate and frequent suckling.

(d) to promote breast-feeding by the education of mothers through the health services

and the mass media, and of future mothers through sensible mothercraft education for

girls, with the quite specific objective of maximizing exclusive breast-feeding to the

age of between four and six months.

5.1.3 Transition diets for infants

It is common practice in the Region that the infant is not given early enough the

supplementary foods which he needs after the age of six months to meet his increased


physiological requirements. The process of adding semi-solids and solids is very

slow, and whatever is given until the age of twelve to eighteen months is often

only additional carbohydrate. Meat, fish or eggs are given only very late and

with great diffidence. There are many taboos surrounding supplementary feeding

which ne'ed to be recognized by health workers. These taboos seem to be related to

the values attached to "soft" or "hard" foods butthey probably have originated in

fear of gastro-intestinal infections. The reluctance to give, at a suitable age,

foods of appropriate nutritive value is responsible for lack of growth. However,

since supplementary food items are given to the child without knowledge of the need

for scrupulous cleanliness, the frequency of diarrhoeal disease increases consider-

ably. In diarrhoea1 disease, food of nutritive value is actually withdrawn from

the child, and the vicious cycle of malnutrition and diarrhoeal disease or other

major infections such as measles has begun. Attempts to produce and package and

market special weaning foods in developing countries have not been very successful

yet. A systematic programme of education needs to be established which will reco-

gnize the existing taboos and defective feeding practices and find ways of correcting

them, and show mothers how to introduce foods suitable to the child's age and needs above all, food items which are familiar and available to the mother in her home

environment . When we are fortunate enough to have the child under the regular supervision of

a trained health worker, it is a serious omission if the nutritional status of the

child is not effectively monitored. The most reliable way for the health worker to

monitor the growth of the child is the use of a weight chart based on a.known inter-

national standard. This has recently been the subject of a multi-country evaluation

by WHO and is extremely simple for recording and for assessment of the nutritional

status. However, it is also important that the health worker understands that assess-

ment alone is not of value. Appropriate education, supplementary feeding or thera-

peutic action should follow diagnosis of failure to make the expected progress.

5.1.4 The Expanded Programme of puniaation

The six immunizable diseases are, as we have shown, important contributors to

early childhood mortality and morbidity. The vaccines to combat them are available

or can be made so. The main obstacles in this Region remain:

(a) the necessity for each government to allocate adequate funds according to its

means. Certainly it is right to take advantage of bilateral or WHO or UNICEF

EM/RC28flech.Disc.l page 19

assistance to implement a programme and attain a coverage which would not otherwise

be possible; but reliance on these sources to meet local costs such as travel al-

lowances, salary supplements, petrol and other transport costs may pose eventually

a threat to the continuation of the programme in a few years' time unless a firm

budgetary commitment is made. It is better to limit the use of outside assistance

to investments such as the cold chain and vehicles and training, and certain cate-

gories of supplies Such as vaccines and the means of administering them, which are

better obtained in this way, partly for technical reasons.

(b) lack of trained capability to solve the complex managerial problems in EPI.

This can be overcome by training, so long as the need for it is recognized,

(=) poor public response. Failure of parents to bring their children tor ~munizatzon

when it is available, and failure to follow through for the necessary three visits

is a serious obstacle which raises enormously the cost per fully-imunized child.

It is, partly, a.manageria1 problem and, partly, one that must be tackled by specific

health education and promotional efforts.

Nevertheless the programe is feasible and cost-effective and is worth pursuing

patiently and diligently.

5.1.5 The treatment of sick children and primary child health care

Before leaving this subject we should say something about paediatrics and hospi-

tal care of sick children. Such provision is necessary, and if beds were to be pro-

vided for the sick according to need then plainly about 50 per cent of all hospital

beds should be for children, instead of about 10 per cent as at present, since they

suffer 50 per cent of all illness. However, one does not advocate such an increase,

On the contrary, hospitalization can contribute very little to reducing the toll of

mortality and morbidity in the young child. The diseases are preventable, and yet in

many countries more money is spent on hospital care than on preventive programmes.

This is particularly inappropriate in the case of young children. Instead, a more

rational aim in respect of treatment of sick children would be to concentrate effort

on;

(a) improving the quality of hospital care in some very basic directions such as bet-

ter nursing, greater cleanliness, less overcrowding, and segregation and barrier-

nursing of highly infectious cases;

(b) better care in the out-patient department, the organization and conduct of which

should be the most important of the specialist paediatrician's duties and not delegated

to a junior;

EM/RC28/Tech.Disc. 1 page 2 0

(c) improvement of quality of care at the village and home level by upgrading the

capability of health centres and dispensaries, supplying them with adequate quanti-

ties of a restricted list of simple but important medicines and other supplies, and

above all by establishing ~rimary health care programmes.

Indeed, it is primary health care, which combines preventive measures with home-

level treatment in the village, which has had the most significant measured impact on

child health in the last five years. We may quote two similar examples from Iran:

After two years, the Ravar Village Health Worker Project near Shiraz has demonstrated

an infant mortality of 64 per 1 000 live births in the project villages compared with

127 in control villages similar in all other ways22, Likewise, the West Azerbaijan

Primary Healttl Care programme shows a very similar change - the infant mortality rate in the villages served fell from 124 in 1973 to 67 in 1976.

In summary, the treatment of sick children should at this stage of development

take second place to prevention., Treatment will always be necessary, nevertheless,

and should be improved by moving it as much as possible towards the home. Finally,

those who have to be admitted should be treated much better,

5.2 Activities directed to the community

There are three important programme elements:

5.2.1 Water supplies and environmental sanitation

Since gastro-enteritis is the most important.cause of death in childhood a re-

duction in the infectious agents that cause it can be obtained on a community scale

only through a supply of safe water in sufficient quantity, This needs to be com-

bined with adequate disposal of human waste and supplemented by fly control mainly

through garbage disposal, Since diarrhoea1 diseases are essentially hand-carried,

through a faecal-oral infection cycle, the provision of water in the house or very

close to it results, through its frequent use, in a dilution of the infection po-

tential. The benefits of this in regard to enteric infections were scientifically

demonstrated more than two decades ago. The limiting factor is the cost, and, pos-

sibly still, a lack of full awareness on the part of governments and local author-

ities of its real benefits, Since the peri-urban slum areas of larger cities are

sometimes those with the highest child mortality, higher even than rural areas, par-

ticular attention needs to be given to them. Only limited progress was made between

1970 and 1975 in urban and rural areas of the Region in regard to both community

water supplies and human waste disposal. In fact, if we face the truth, it would be

~M/RC28/Tech.Disc. 1 page 21

more c o r r e c t t o say t h a t no progress was made, because minor ga ins i n some d i r e c t i o n s

were o f f s e t by d e t e r i o r a t i o n i n o the r s . For example, we see from VJorld Health S t a t i s -

t i c s Report Vol. 29 No.10, 1976 t h a t t h e percentage of t he urban populat ion i n t he

Eas te rn Mediterranean Region i n households connected t o a pub l i c sewerage system rose

from 7 per c e n t i n 1970 t o 10 per c e n t i n 1975 (compared wi th 15 per cen t i n African

Region, 24 per c e n t i n Western P a c i f i c Region, 26 per c e n t i n South Eas t Asia and 35

per cen t i n L a t i n America). However, t h e percentage of urban populat ions i n t he

Region i n households served by any system of e x c r e t a d i sposa l a t a l l , even buckets ,

r o se only from 62 t o 63 per cen t i n those f i v e years , aga in t h e l o w e ~ t i n t he world.

The percentage of r u r a l popula t ion i n our Region wi th adequate e x c r e t a d i sposa l ro se

from 12 per c e n t i n 1970 t o 14 per cen t i n 1975. Likewise wi th r e spec t t o water sup-

p ly , t h e percentage of urban households w i th piped water connexions i n t he house ac tua l -

l y decreased from 56 pe r c e n t i n 1970 t o 52 per c e n t i n 1975, t he only Region t o have

a decrease. The percentage o f r u r a l popula t ion wi th in reasonable access t o a s a t i s f a c -

t o r y water supply a l s o decreased i n t h i s Region from 19 per c e n t i n 1970 t o 16 per

cen t i n 1975 - aga in t he only Region t o have a decrease. It is q u i t e obvious t h a t , f a r

from making any r e a l progress , water supply and exc re t a d i sposa l a r e ha rd ly keeping

pace o r no t keeping pace wi th popula t ion growth; and t h a t t h i s Region i s the worst-

served i n t h i s r e spec t of a l l Regions, by a cons iderable margin.

There a r e c o n s t r a i n t s o t h e r than f i n a n c i a l i n t h e way of improvement. On may be

t h a t m i n i s t r i e s of health,who a r e most aware of t he need, a r e o f t e n no t mainly responsi-

b l e f o r water supply and e x c r e t a d i sposa l . Another c o n s t r a i n t i n some coun t r i e s can be

manpower shor tage , e s p e c i a l l y shor tage of people t o superv ise cons t ruc t ion hones t ly

and competently, t h e a b l e s t having gone t o r i c h e r coun t r i e s f o r b e t t e r pay. Never-

t h e l e s s , i n many of t h e coun t r i e s w i th t he g r e a t e s t need t h e c o n s t r a i n t s are mainly

f i n a n c i a l , with, a s we l l , the l a c k of sense of urgency and p r i o r i t y . Once t h e latter

f a c t o r i s overcome, t h e f i n a n c i a l c o n s t r a i n t could be overcomeby t h e c r e a t i o n of a

r eg iona l programme wi th s p e c i a l emphasis i n t h i s f i e l d . This would n e c e s s i t a t e a

pooling of r e sou rces from the wea l th i e r c o u n t r i e s of t h e Region and could be pa t t e rned

i n broad o u t l i n e on t h e r eg iona l water supply programne sponsored i n t h e Americas.

5.2.2 Control of ma la r i a

The second comnunity-based programme requ i r ed is ma la r i a prevention, because f o r

some c o u n t r i e s , a s has been shown, ma la r i a is s t i l l a major cause of morbidi ty and

m o r t a l i t y i n t h e c h i l d under three . C lea r ly each country should pursue, and where

necessary i n t e n s i f y , i t s p re sen t ma la r i a c o n t r o l programme, and i n t h e hyper-endemic

EM/RC28/Tech.Disc. 1 page 22

a r e a s t he programme needs cons iderable f u r t h e r e f f o r t s s t i l l . On the o t h e r hand,

malaria a s f a r a s t he young c h i l d is concerned perhaps belongs i n t he previous

s e c t i o n on " A c t i v i t i e s devoted t o t he c h i l d and the family", because the expansion

of primary h e a l t h ca re coverage would be most h e l p f u l t o ma la r i a con t ro l programmes

s o t h a t more cases of f eve r could be i n v e s t i g a t e d and t r e a t e d ; and i n p a r t i c u l a r

because t h e most immediately p r a c t i c a l way t o reduce morbidi ty and m o r t a l i t y i n

c h i l d r e n under t h r ee years of age i n hyper/holo-endemic a r e a s would be by chemo-

prophylaxis . This n e c e s s i t a t e s t h r e e th ings : ( a ) coverage, (b) i n s t r u c t i o n of

s taff ,and (c ) provis ion of s u i t a b l e drugs i n s u i t a b l e form f o r ch i ld ren i n adequate

q u a n t i t i e s . The aim of chemoprophylaxis i n hyperendemic a r e a s i s not t o t a l prophy-

l a x i s bu t s i g n i f i c a n t and l i fe -saving mi t iga t ion and postponement of i n f e c t i o n t o a

l a t e r age when the c h i l d can more e a s i l y withstand the i l l n e s s .

5.2.3 Food and n u t r i t i o n p o l i c y

By and l a r g e , m a l n u t r i t i o n i n e a r l y childhood does n o t i n t h i s Region (ye t )

a r i s e s o much from abso lu t e food shor tages a s from t h e combination of i n f e c t i o n s

with poor infan t - feeding p r a c t i c e s . Overa l l supply throughout t h e Region is more

than enough t o meet phys io logica l requirements. There a r e , however, problems of

uneven d i s t r i b u t i o n wi th in t he c o u n t r i e s , which a r e b e s t reso lved by means of a na-

t i o n a l food and n u t r i t i o n pol icy , which involves i n v e s t i g a t i n g t h e problems and me-

chanics of food d i s t r i b u t i o n and in t e rven ing t o c o r r e c t de fec t s . I n t e rven t ions in-

c lude p r i c e c o n t r o l s , food subs id i e s , b e t t e r s t o rage and p re se rva t ion f a c i l i t i e s f o r

food, and more r a t i o n a l planning of food imports and expor t s t o match t h e needs of

t he l o c a l market and s t a b i l i z e pr ices .

The o t h e r reason f o r formula t ing n a t i o n a l food and n u t r i t i o n po l i cy i s the pos-

s i b l e f u t u r e s i t u a t i o n of t he world vis-&vis food supply. Nobody can r e a l l y w i th

confidence d ismiss t h e p red i c t i ons of d i s a s t e r made by the Club of Rome and l a t e l y

by t h e US National Academy of Sciences. Wise coun t r i e s t h a t wish t o su rv ive w i l l

implement food p o l i c i e s which aim a t decreas ing t h e i r dependency on food imports.

Las t ly , t h e r e are s t i l l l o c a l shor tages of b a s i c foods occu r r ing i n c e r t a i n

a r e a s of our Region a f t e r poor harvests ,which a sound food and n u t r i t i o n po l i cy can

he lp t o m i t i g a t e and even avoid. This i s important f o r c h i l d h e a l t h , s i n c e i n such

a s i t u a t i o n of shor tage the c h i l d under t h r e e years of age, i n h i s marginal n u t r i -

t i o n a l s t a t e , s u f f e r s much more than the o l d e r c h i l d , a s t h e FAO/WHO/UNICEF r e p o r t 2 3 on Food and N u t r i t i o n Pol icy i n Somalia shows very we l l .


5.3 Some thoughts on maternal h e a l t h and i t s r e l a t i o n t o c h i l d h e a l t h

Since i t i s the mother who has t o nu r tu re t h e c h i l d i n t h e womb, b r ing him f o r t h

i n t o t h e world and cont inue i n another c lo se a s s o c i a t i o n dur ing l a c t a t i o n , a l l can

recognize t h a t t h e r e i s an important r e l a t i o n between maternal h e a l t h and c h i l d hea l th .

I n p a r t i c u l a r , maternal n u t r i t i o n , spacing of pregnancies , q u a l i t y of a n t e n a t a l ca re

and c a r e dur ing c h i l d b i r t h , a l l have a d i r e c t r e l a t i o n t o t h e h e a l t h of the c h i l d a t

b i r t h and f o r many months a f te rwards a l s o ,

However, maternal h e a l t h has a paison d'&2e and a p r i o r i t y of i t s o m , a s wel l

a s i n r e l a t i o n t o the ch i ld . Child h e a l t h and maternal h e a l t h a r e no t simply ad junc t s

one of t h e o the r . Every country needs t o p l an and implement a programme of maternal

h e a l t h i n i t s own r i g h t , wi th c l e a r and s p e c i f i c o b j e c t i v e s , j u s t a s it needs a pro-

gramme of c h i l d hea l th . And j u s t a s a succes s fu l environmental h e a l t h programme w i l l

have a b e n e f i c i a l i n f luence on c h i l d hea l th , so a l s o , and even more d i r e c t l y , w i l l a

succes s fu l maternal h e a l t h progranune.

6 . CONCLUSION

The s t a t e of c h i l d h e a l t h i n t he Region has been reviewed. The problems and

p r i o r i t i e s a r e numerous, bu t one s t ands out : t h e almost two m i l l i o n dea ths and ac-

companying morbidi ty i n t h e c h i l d under t he age of t h r e e years . It i s suggested t h a t

a t p r e sen t t he g r e a t e s t c o n t r i b u t i o n which could be made t o c h i l d h e a l t h would be t o

concent ra te e f f o r t s on s p e c i f i c a c t i o n s t o reduce permanently t h i s mor tad i ty t o f a r

lower l e v e l s . These s p e c i f i c a c t i o n s a r e considered i n turn. They a r e summarized

i n Table 4.

It remains now i n t h e l i g h t of the Cons t i t u t i on and commitments of WHO, which

comprises t h e Member S t a t e s and i t s S e c r e t a r i a t , t o t ake advantage of I n t e r n a t i o n a l

Year of t he Child and the i n t e r e s t c r ea t ed thereby i n order t o t r a n s l a t e t h e consider-

a t i o n s which have been t h e s u b j e c t of t h i s paper i n t o p r a c t i c a l a c t i o n s which w i l l make

a permanent c o n t r i b u t i o n t o c h i l d h e a l t h , Within each m i n i s t r y of h e a l t h t h e p i ' t i fu l

s i t u a t i o n and overwhelmingly predominant needs of t h e young c h i l d should r ece ive a

j u s t r ecogn i t i on which expresses i t s e l f i n ac t i on . Within each government and commu-

n i t y t he s i t u a t i o n of t he se ch i ld ren , which is as f a r from t h e enjoyment of t h e i r

r i g h t t o hea l thy growth a s i s dea th from l i f e , should a l s o r e c e i v e r ecogn i t i on i n

p r a c t i c a l ac t i on . F i n a l l y , i n t h e i r r e l a t i o n s w i th WHO, UNICEF, UNDP and t h e o t h e r

i n t e r n a t i o n a l agencies , and wi th b i l a t e r a l agencies , and i n t h e i r m u l t i l a t e r a l and

E~/RC28/Tech.Disc.l page 24

bilateral relations, it is for the government to make it clear that the health of

the young child has a treble priority: a priority within all health programmes,

a priority within all efforts for the improvement of the welfare of chil&en, and

a priority in the social development of the nation.

Table 1

Child mor t a l i t y i n t he Eastern Mediterranean Region (Estimated from l a t e s t da t a a v a i l a b l e t o WHO/EMRO)

* Estimated - by analogy wi th o t h e r c o u n t r i e s with similar IMR

Country

Afghanistan Bahrain Cyprus Democratic

Yemen Dj ibou t i Egypt I r a n I r aq I s r a e l Jordan Kuwai t Lebanon Libya Oman Pabis t a n Qatar Saudi Arabia Soma1 ia Sudan Syr ia Tunis ia UAE Yemen A.R.

Tota ls

(1)

Estimated popula t ion

1977 (000's)

20 340 270 690

1 8do 230

38 740 34 160 11 910

3 610 2 080 1 130 3 060 2 570

8 20 75 280

200 9 520 3 350

16 530 7 840 6 070

760 7 080

248 040 I

(2)

Crude b i r t h r a t e

4 9 45 19

45 38 35 4 7 4 2 2 6 50 51 33 45 50 50 50 49 4 7 49 48 36 50 4 9

1

(3)

Crude death r a t e

24 7

10

23 12 1 2 15 10

7 15

6 8

14 19 16 20 19 2 2 2 1 15 14 18 25

(4)

Estimated l i v e b i r t h s

1977 (000 ' s )

997 1 2 1 3

8 1 9

L 356 1 605

500 94

104 58

10 1 115 41

3 765 LO

466 157 810 376 218

38 34 7

11 273 L

( 5 ) In fan t

m o r t a l i t y r a t e

182 64 3 3

190 52

100 139 86 2 1 8 9 43 6 5 7 3

138 124 4 2

152 177 140 9 3

120 138 152

(6)

Estimated i n £ a n t deaths

1977

181 500 800 400

15 400 500

135 600 223 I00 43 000

2 000 9 300 2 500 6 600 8 400 5 700

466 900 400

70 800 27 800

113 400 35 000 26 200

5 200 52 700

1 433 000

(9)

Estimated deaths

1-4 years

(8 minus 6) 1977

62 600 100 300

5 300 300

93 600 33 100 10 600

500 2 700

500 2 000

10 200 2 100

181 100 1 200

19 60C 9 000

60 200 6 300

15 900 1 000

35 800

554000

(7)

Deaths 0-4 years

a s per c e n t of

a l l deaths

50* 45* 10"

50" 30' 49.3 SO* 45*

9.8 38.6 44.5 35* 5118 50 5328

:4 50" SO* 35,l 49.6

45: 50

\

(8)

Estimated deaths

0-4 years 1977

244 100 900 700

20 700 800

229 200 256 200 53 600

2 500 12 000 3 000 8 600

18 600 7 800

648 000 1 800

90 400 36 800

173 600 41 300 42 100

6 200 88 500

1 9 8 7 0 0 0 1


Table 2

Percen tage p r e v a l e n c e a t t i m e of examinat ion of d i a r r h o e a , measles and r e s p i r a t o r y i n f e c t i o n s , i n Manshaar e l Bakary (M)

and S a f t el Laban (S) , Egypt

Age (months)

0-3 M S

4-6 M S

7-11 M S

0-11 M S

12-23 M S

24-35 M S

36-47 M s

12-47 M S

0-47 M S

48-59 M S

60-71 M S

0-71 M S

Recent d i a r r h o e a

1.8 3.6

5.1 6 3

9.4 17.2

6 .O 11.0

17.8 22.2

11.2 13.1

3.7 3.7

11.7 13.4

10.5 12.8

4.7 2.7

1.3 1.2

8 7 10.0

Number examined

57 2 8

7 9 3 2

9 6 58

232 118

34 3 158

303 137

244 137

8 90 432

1 122 550

215 111

157 8 6

1 494 747

Cur ren t d i a r r h o e a

22.8 17.9

26.6 9 e.4

39.6 29.3

31 .O 21.2

33.8 20.3

25.7 19.7

11.9 17.0

25.1 16.0

26.3 17.1

5.1 3.6

1.9 0.0

20.7 13.1

R e c u r r e n t d i a r r h o e a

- 7.1

- 6.3

- 32.8

- 19.5

- 36.7

- 77.6

- 8 00

- 23.2

- 22.4

- 1.8

- 0 00

- 16.7

0.0 0.0

0.0 0.0

5 2 0.0

2.2 0.0

1.5 0.6

1 e 3 2.9

4.1 1 6

2.1 1.6

2.1 1.3

2.3 0.0

0.0 0.0

1.9 0.9

R e s p i r a t o r y i n f e c t i o n

0.0 0.0

0.0 0.0

1.0 1 7

0.4 0.9

0.6 0.6

0.0 10.2

0.4 0.0

0.3 3.4

0.4 2.9

0.0 2.7

0.0 0.0

0.3 2.5


Table 3

Percentage of children receiving different types of feeding at different age groups in Manshaat and Saft villages in Rural Egypt

Age (months)

Number

116

116

171

172

173

130

159

8 5

45

7 3

66

92

7 3

64

6 5

72

M

A

N

S

iL

A

A

T

S

A

F

T

0 - 5

6 - 11 12 - 17 18 - 23 24 - 29 30 - 35 36 - 41 42 - 47

0 - 5

6 - 11 12 - 17 18 - 23 24 - 29 30 - 35 36 - 41 42 - 47

Breast

100.0

98.3

95.9

69.8

41.6

16.2

4.4

0.0

97.8

100.0

92.4

76.1

21.9

4.7

4.6

0.0

Only breast

93.1

66.4

9.9

3.5

0.6

0.0

0.0

0.0

88.9

72.6

13.6

7.6

0.0

0.0

0.0

0.0

No breast

0.0

1.7

4.1

30.2

58.4

83.8

95.6

100.0

2.2

0.0

7.6

23.9

64.4

95.3

95.4

100.0


Table 4

Summary of priority activities recommended for reduction of mortality in children under three years of age

(Section 5 of the paper)

Section

5.1 ~ctivities directed towards the child and his family

5.1.1 Promote widest possible use of oral rehydration salts in acute diarrhoea

(a) Government commitment needed

(b) Secure an adequate supply. Local production and packaging

(c) Make available to the public, inform and convince mothers to use it

5.1.2 Promotion and protection of breast-feeding

(a) convey recent knowledge to all health personnel

(b) forbid public advertising of powdered milk for bottle-feeding

(c) change obstetric ward practices to favour breast-feeding

(d) promote it through education of mothers and mothers-to-be

5.1.3 Better weaning or transitional diet for infants

(a) identify locally available familiar foods suitable for feeding infants

(b) find ways to prepare them suitably and test their effect on child growth

(c) educate and inform mothers how to use them

5.1,4 Expanded Brogramme of Immunization

(a) Government financial commitment

(b) Training to solve management problems in EPI

(c) Secure better public response through good management and specific promotional efforts

5.1.5 Treatment of Sick Children and Primary Child Health Care

(a) move treatment away from hospital towards the home through primary health care programmes

(b) improve children's out-patient departments

(c) better nursing of those who have to be admitted

5.2 Activities directed to the community

5.2.1 Water Supplies and Environmental Sanitation

(a) give it more priority in national development

(b) do more to remove financial constraints


5.2.2 Malaria Control

(a) extend primary health care for more diagnosis and treatment of feverlpos- sible malaria

(b) provide chemoprophylaxis in hyper-endemic areas to as many children under three as possible

5.2.3 National Food and Nutri~ion Policy

(a) intervene to stabilize food prices

(b) plan for greater future national self-sufficiency in food

(c) build up buffer stocks at provincial level against basic food shortages due to poor harvests

5.3 Maternal Health

A maternal health programme has a priority in its own right and because of

significant impact on child health. Every country needs to plan and implement a

maternal health programme with clear specific objectives.

EM/RC28/Tech.Disc.l paqe 30

F i g u r e 1

Reported and Adjusted Death Rates ( a l l ages) , Egypt

F i e u r e 2

/

Infant Mortality, Egypt

YEAR

EM/RC28/Tech.Disc.l page 3 2

F i g u r e 3

L i f e c h a r t of one c h i l d from Santa Maria cauquL, from b i r t h t o t h r e e yea r s of l i f e ,

showing t he weight curve i n comparison w i th t he median of t h e Iowa s tandard

(Jackson and Kel ly 1945). I l l n e s s e s a r e shown under t he curve;

d u r a t i o n of i l l n e s s i s represen ted by t he l eng th of t h e

h o r i z o n t a l l i n e s

(2 KEY

1 4 - -

1 3 .

12- .

_ / 0. A 'ABSCESS He/

BC -BRONCHITIS A/0

BN -BRONCHOPNEUMONIA CONJ=CONJUNCTIVITIS

-.-/- 0-

D .DIARRHEA , /*. I - IMPETIGO M -MEASLES , S - STOMATITIS T -ORAL THRUSH

,/*' 0

VRI - UPPER RESF! TRACT ILLNESS I1 -

10 -

9 -

3 -

2 -

k l

r o 3 6 9 12 IS 1 0 21 2'4 i7 3 0 33 36

A G E I N M O N T H S

F i g u r e 4

R A T I O S OF D E A T H R A T E S AND S O C I O - E C O N O M I C V A L U E S I N S E V E N C O U N T R I E S

T O U N I T E D S T A T E S R A T E S AND V A L U E S ( d a t e for 1 9 5 6 )

R A T I O S T O U N I T E D S T A T E S M E A S U R E S R A T I O S T O U N I T E D S T A T E S R A T E S

L i t e r a c y

W a t e r s u p p l y

a A n i m a l p r o t e i n

P e r c a p i t a income

- 1 y e a r s

1-4 y e a r s CANADA

ARGENT l HA

CH l L E

V E N E Z U E L A

MEX l C O

COLOMB l A

GUATEMALA

WOO

EM/RC28/Tech.Disc.l page 3 4

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