Child Survival: The Silent Emergency
NOVA charts the progress of an ambitious worldwide health program established to save the lives of millions of children who continue to die from common but curable diseases.
Transcript
00:00Each year, in the developing world, 15 million children die before reaching the age of five.
00:17And now a strategy to save those children is being put to the test worldwide.
00:21Tonight, NOVA tracks the progress of what is being called a child survival revolution.
00:28One concern is that developing countries are already experiencing skyrocketing population
00:34growth.
00:35If this child survival strategy succeeds, how will it affect parents' attitudes toward
00:40the number of children they will have?
00:43Child survival, the silent emergency.
00:51Major funding for NOVA is provided by this station and other public television stations
00:55nationwide.
00:57Additional funding was provided by the Johnson & Johnson family of companies, supplying healthcare
01:02products worldwide.
01:07And Allied Corporation, a world leader in advanced technology products for the aerospace,
01:12automotive, chemicals, and electronics industries.
01:41The death of a child, possibly the greatest tragedy most people can imagine.
01:48It has been said that children are the future, that they represent the true wealth of a society.
01:56Yet each year, 15 million children in the developing world die before reaching the age
02:02of five.
02:04And in poor communities like this one, the funerals of children are common events.
02:14In the next hour, as you watch this program, 1,700 children around the world will die from
02:21a handful of preventable illnesses.
02:24This film will examine a new effort to save the lives of millions of children like them.
02:41In the fall of 1984, American television viewers were stunned to see images like these of children
02:48starving in Ethiopia.
02:51These were the pictures of a loud emergency, and hundreds of thousands of people responded
02:56swiftly and generously.
02:58But the crisis goes on, and what the world did not hear was that these children represent
03:04only a small fraction of a quieter, everyday epidemic of child mortality.
03:12At the United Nations Children's Fund, UNICEF, Executive Director James Grant.
03:18Children need an advocate, really, for two reasons.
03:22One, they are the most important asset this world has, and the most precious.
03:28They are our future.
03:30Secondly, they are the most underrepresented.
03:34They themselves can't speak out on their own behalf, and a great many of their parents
03:39are in that position.
03:40And this is why it's so important for organizations like UNICEF, but not only UNICEF, but for
03:45political leaders and other organizations to take on an advocacy role for them.
03:51In late 1982, UNICEF launched a worldwide strategy for saving the lives of up to seven
03:57million children each year.
04:00It was called the Child Survival Revolution.
04:03This program will investigate early results of this strategy and a surprising impact it
04:08may have on world population.
04:13What kills children is remarkably similar all over the developing world, and it's not
04:18the exotic tropical diseases one might imagine.
04:21The biggest killer is diarrhea.
04:24Five million children die each year of dehydration caused by diarrhea.
04:30Next is the common cold, which becomes pneumonia, taking about four million lives annually.
04:36Working in deadly cycle with diarrhea is malnutrition, even more often caused by infections than by
04:43too little food.
04:45Four million children die of immunizable diseases, tetanus, diphtheria, measles, polio, tuberculosis,
04:53and whooping cough.
04:54An equal number become blind, deaf, mentally retarded, or disabled.
05:02UNICEF's four-step strategy to fight infant mortality is known as GOBI, which stands for
05:08G, growth monitoring, to inform parents if their children are adequately nourished and
05:13growing steadily.
05:15O, oral rehydration therapy, an almost miraculous solution which prevents death due to dehydration
05:23from diarrhea of virtually any cause.
05:27B, breastfeeding education, to inform parents of the nutritional and immunological benefits
05:33of breastfeeding, as well as its contraceptive effect.
05:37And I, immunization of all children against the six major childhood diseases.
05:44UNICEF is only one of a number of international agencies carrying out child health interventions.
05:50Many have endorsed GOBI, but the strategy is not without its critics.
05:54Some suggest that the child survival revolution may worsen an already serious population problem.
06:00For centuries, world population grew slowly.
06:04But with better living standards and health care, since 1800 the rise has been dramatic.
06:10Today's population of five billion is projected to double by the year 2050.
06:15Ninety-six percent of that growth will occur in developing countries.
06:19Some say UNICEF should promote family planning as part of child survival.
06:23I think you have to implement birth control along with death control, or otherwise in
06:29the long run it's going to be a self-defeating and ineffective strategy.
06:32In other words, the child survival strategy has got to bring family planning strongly
06:37into the picture and vigorously support this aspect of their health programs.
06:43UNICEF claims the GOBI strategy may eventually bring about lower birth rates.
06:48We are learning that in the great majority of cases, successful implementation of child
06:53survival revolution should actually result in a decline in population growth rate, and
06:59that by the end of this century, 15 years from now, successful implementation of the
07:04child survival revolution would mean substantially lower population growth rate than without it.
07:10Now, the reasons are several, but at the heart of it is the fact that when a mother knows
07:20that she herself can control the health of her child through oral rehydration therapy,
07:25through monitoring, through getting the child immunized, she then is much more willing and
07:33much more ready to have a smaller family.
07:37Early results of GOBI can be seen in Bangladesh, Haiti, El Salvador, and Brazil, four developing
07:43nations where UNICEF, other health agencies, and governments themselves are putting this
07:48strategy into action.
07:53The story of the child survival revolution begins here in Dhaka, Bangladesh, where a
07:59low-tech discovery of 15 years ago provided the pivot upon which the GOBI strategy turns.
08:06Bangladesh is one of the poorest and most densely populated nations in the world.
08:11Ninety-three million people live in an area the size of Wisconsin.
08:15Per capita income is $140 per year.
08:20Bangladesh has one of the highest infant mortality rates worldwide.
08:24A hundred and thirty of every thousand children born die before reaching their first birthday.
08:30The leading cause is dehydration due to diarrhea.
08:35This child is suffering from Shigella, a common illness in Bangladesh which does serious damage
08:40to the intestine.
08:41Other diarrheal diseases are caused by dozens of viruses and bacteria, among them E. coli,
08:47cholera, and rotavirus.
08:51Diarrhea is an illness of poverty associated with impure water, lack of sanitation facilities,
08:57and poor hygiene.
08:59During the Bangladeshi War for Independence in 1971, a new and astonishingly simple treatment
09:05for diarrheal dehydration proved its effectiveness when a cholera epidemic swept through refugee
09:11camps.
09:12Death rates were held to an extraordinarily low 3.6 percent with a salt, sugar, and water
09:18solution administered to patients by mouth.
09:21Oral rehydration therapy has since been hailed by the British medical journal Lancet as potentially
09:27the most important medical advance of the century.
09:31Thousands of diarrhea patients are brought to Dhaka each year for treatment at the International
09:36Center for Diarrheal Disease Research, Bangladesh, or the ICDDRB.
09:42Thirty-eight countries and international agencies help to fund this center.
09:47This child does not have pneumonia then, although he has a cough.
09:51An early pioneer of oral rehydration therapy, or ORT, is Dr. William Greenough.
09:58Our best science has tended to overlook the main health problems on the planet, which
10:03are the communicable diseases here in developing country settings.
10:07The principle of the center here is to apply the best knowledge we have to the greatest
10:13problems in health in the world, not just in Bangladesh.
10:18And diarrhea tops the list.
10:20The problem in dehydration is twofold.
10:23The intestinal wall becomes damaged, losing its ability to take in salt, which normally
10:28helps the body to retain water.
10:30In addition, the body expels large amounts of fluids through secretion.
10:35After a period of days or even hours, the child may go into shock.
10:40Blood pressure drops, the kidneys shut down, and death follows within hours.
10:45Intravenous rehydration was perfected in the 1950s and long remained the treatment of choice,
10:51though expensive and hard to obtain in developing countries.
10:56It is still used with babies who are in shock or comatose like this one and who cannot take
11:01fluids by mouth.
11:04The breakthrough of ORT came when scientists discovered that glucose or sugar helps the
11:10intestine to absorb salt and water, allowing the body to replace lost fluids.
11:15ORT doesn't cure diarrhea, which will usually stop on its own, but ORT does prevent most
11:22children from dying of dehydration.
11:25Nine o'clock, this dehydrated child has lost 10% of his body weight.
11:30Without treatment, death would be hours away.
11:349.15, he is encouraged to take the ORT solution.
11:39Noon, the child is rehydrated, alert, and out of danger.
11:44By 1.15, the child's appetite is returned and he is able to breastfeed.
11:51The ingredients of homemade ORT are one liter of water, 3.5 grams of salt, and 40 grams
11:57of sugar.
11:59Here at the ICDDRB, scientists are working to improve ORT.
12:05Their new formula uses rice or other starches instead of sugar.
12:09Rice offers an added nutritional advantage.
12:13Rice is now our main form of oral rehydration therapy, which you will see in the hospital.
12:19Its advantages are several.
12:22It not only rehydrates, but it shortens diarrhea, it decreases the amount of fluid loss, and
12:29we have shown that children have half the attack rate of diarrhea subsequently if they
12:34are treated each attack with the new rice solution.
12:50It is hoped that ORT's dramatic results will increase parents' confidence that they can
12:57take steps to save their own children's lives.
13:01This is the essence of the Gobi strategy, not to create reliance upon doctors, nurses,
13:06and often faraway clinics.
13:10Even in poor rural households in Bangladesh, the ingredients of either rice or a molasses-based
13:15ORT solution are usually available.
13:19But the discovery of oral rehydration therapy can be effective only if parents know how
13:23to prepare it and are convinced that, indeed, it can save their children's lives.
13:30The challenge is to make the knowledge as widely available as possible.
13:34F.H. Abed took up that challenge, organizing a veritable army of 900 health workers called
13:44the Bangladesh Rural Advancement Committee.
13:47Knowing that decisions in Bangladeshi households are often made by men, Abed has been holding
13:52village meetings all over the country to make sure community leaders are in support of ORT.
14:05To reach mothers with news of ORT, female health workers from the committee visit ten
14:10houses each day.
14:12They teach mothers to make ORT solutions using a three-finger pinch of salt combined
14:17with a fistful of molasses, which is dissolved in water.
14:21Basically, we are trying to cover all the women in Bangladesh.
14:26We are going from one house to another, one by one.
14:30We have so far done 4.2 million families, until last month, and we have to cover all
14:35the 13 million households in Bangladesh.
14:38It will take us another three and a half years.
14:42By June 1989, we should cover the entire country.
14:47With a population of more than 90 million projected to double within 30 years, Bangladesh
14:52faces two seemingly paradoxical concerns, decreasing the death rate of its children
14:58and reducing the size of its families.
15:01UNICEF does recommend that families space their births more than two years apart, but
15:06it's fallen short of making family planning a basic element of its strategy.
15:12Bangladeshis are 85% Muslim, a religion which recommends what it calls responsible parenthood,
15:18having only those children parents are able to care for.
15:23A decade ago, a group called Concerned Women for Family Planning began an outreach effort
15:28to the slums of Dhaka.
15:31Concerned Women for Family Planning, as the name suggests, this started as a family planning
15:36program.
15:37And in this program, the women go out in the slum areas, knock each and every door, talk
15:43to the women, and educate them about the family planning methods, and help them in choosing
15:49a method for themselves.
15:50We tell our field workers that whenever you go out, dress very simply, sit down with them
15:56on their floor, eat with them, talk to them, and be friends.
16:07In addition to distributing birth control pills and condoms, the group offers information
16:15on ORT, prenatal care, and nutrition.
16:20Mufaiza Khan has learned that since the majority of Bangladeshi women very seldom leave their
16:25courtyards, even to go to the marketplace, delivery of such information must be compatible
16:31with their culture.
16:33As women, we feel that we want to do this service with love, dignity, and care, and
16:39provide the services to the other women who are thinking that these are our own sisters.
16:45And usually, the resistance we get from the mother-in-laws, sometimes from the husbands,
16:50because they feel we are spoiling their wives, their daughter-in-laws, so we have to be friendly
16:56with the mother-in-laws and with the husbands.
17:03Only 50 miles from Dhaka, in the fertile lowlands of the Matlab district, life goes
17:15on much as it has for the past few centuries.
17:19One can travel almost anywhere in Bangladesh by a vast network of rivers.
17:25Parents bring their sick children by country boat to a hospital and field station run by
17:29the ICDDRB here on the banks of the Meghna River.
17:36This clinic has been operating for more than 20 years and has been the site of many internationally
17:41known research studies of public health and fertility.
17:46Mothers unfamiliar with ORT bring their children here and keep a quiet vigil, staying with
17:52them overnight while they receive treatment.
17:55ORT carries the vast majority of the babies back from the brink of death within hours.
18:02But sometimes dehydration is complicated by other problems.
18:06This three-year-old boy was brought in by his grandmother and was in a coma from severe
18:11dehydration.
18:12Unfortunately, he was also suffering from an advanced case of roundworm, and doctors
18:17here were unable to save him.
18:20Three hours after he was brought in, he died.
18:28Infant mortality is still high here, but significant improvements have been made in the past eight
18:34years.
18:35Since then, Matlab has been the site of an ICDDRB family planning and maternal and child
18:41health project.
18:43The question is, if child survival improves, how will that affect parents' attitudes
18:48toward using contraception?
18:51Skilled female workers offer family planning advice along with vaccinations, prenatal care,
18:57and instruction in ORT.
19:04As parents have become involved in ORT, death rates have declined by 21 percent.
19:09At the same time, contraceptive use has risen from 8 percent to 45 percent, and birth rates
19:16have fallen by 21 percent.
19:20The eyes of the world are on the Matlab study, in the hope that results here point to a pattern
19:25the rest of the developing world will follow.
19:29The Matlab study showed us that you can accomplish two things at once, that you can have children
19:37survive and you can also have no increase in population growth rate, in fact, a lessened
19:43population growth rate.
19:45This is, I think, what everyone is seeking for, both in developed and developing countries,
19:50and the Matlab experiment demonstrates that this is possible.
19:55The news from Matlab is encouraging, although it's difficult to establish with certainty
19:59that improved child survival will be followed by lower birth rates everywhere in the world.
20:07And it is important to realize that the desire for large families is deeply rooted in many
20:12cultures.
20:14People have children because they want children.
20:18Apart from the fact that they want children for utilitarian purposes, like children are
20:25often the only source of energy they have to do certain things, for instance, like fetch
20:31and carry water, to help out in the rice field, all over the world, all of us human beings
20:38have come through 10,000 years of an agrarian civilization.
20:45And in an agrarian civilization, surely the highest personal value is fertility, because
20:51these are rooted in agrarian values, a whole culture.
20:57Now people who still live in feudal agrarian circumstances, they very much hold on to these
21:05fertility values.
21:07People don't understand why a child, another child, is not one of God's blessings, as it
21:14always was for 10,000 years.
21:18Population experts speak of three demographic stages.
21:21In the first, traditional societies experience high death rates and high birth rates, often
21:27cancelling each other out.
21:29In the second stage, as in many developing countries today, birth rates remain high while
21:34death rates come down with improved living standards.
21:38And in the third, as in many developed countries, death rates and birth rates are both low and
21:44population stabilizes.
21:47It's also instructive to consider our own historical experience.
21:52New York City in 1900 had an infant mortality rate of 140 deaths per thousand, higher than
21:58Bangladesh has today.
22:01Major causes of death then were the same as in developing countries now, diarrhea, pneumonia,
22:07and infectious diseases such as measles and tuberculosis.
22:12As these diseases were controlled, and with new family planning methods becoming available,
22:17birth rates fell sharply.
22:20Must third world countries today reach the same stage of economic development before
22:25the health of their children can improve?
22:27After World War II, it was hoped with an infusion of monies and technology that indeed
22:33economic development and human welfare would proceed at a very rapid pace.
22:38We found this is difficult.
22:40We found that we cannot deliver health services such as they have in Europe or the United
22:43States to everyone in the world.
22:46Child survival revolution is, in a very real sense, a shortcut, is doing with technologies
22:53what we know we can do on a high coverage basis.
22:57Dr. John Rohde has lived in Haiti for the past five years, where he has been helping
23:02the government to set up nationwide campaigns using Gobi interventions.
23:08Following an ORT campaign, surveys showed that the percentage of mothers using ORT for
23:13their children's diarrhea had risen from 2% to more than 80%.
23:19Growth is often impaired by diarrhea, so this mother has been monitoring her child closely
23:24after a recent episode.
23:47Port-au-Prince is the capital city of Haiti, the poorest nation in the Western Hemisphere.
23:53Children's per capita income is $300 a year, and especially hard times in the countryside
23:58are sending a steady flow of migrants into the capital.
24:02Although Haiti's dictatorship has been strongly criticized for its record on human rights
24:06and services, it has allowed Gobi programs to be set up here, often carried out by private
24:12health groups with funds from the U.S. Agency for International Development.
24:18Infant mortality here is high, and if the Gobi strategy can make a difference, it will
24:22bode well for its success elsewhere.
24:25Dr. Jean Pape has been instrumental in spreading ORT throughout Haiti.
24:31Nearly all Haitian doctors-in-training spend time with him here at University Hospital.
24:37At first, Dr. Pape encountered resistance to ORT.
24:41The medical community claimed that intravenous treatment was superior and that ORT was not
24:46widely used in the United States.
24:49We had a lot of difficulties to get various people to accept oral radiation therapy in Haiti.
24:58What you have to realize is that we started in September of 1980 at a time when the major
25:04textbooks, medical textbooks in the United States, were not even mentioning ORT as any
25:12kind of alternative in the treatment of diarrheal illness.
25:16So it looked like we were experimenting here at first.
25:22Number two, physicians had been used to intravenous fluids with success, and it was very hard
25:30for them to make the transition.
25:32And number three, it looked too simple for physicians for it to work.
25:37I think that for the mothers, we essentially had no problem at all.
25:41The mothers are admitted with their children, and they do see the results, and actually
25:45they are the best promoters of ORT.
25:47Mortality in this ward has dropped from 38% to less than 1% in the past five years.
25:54There has also been a strong breastfeeding campaign in Haiti.
25:58Many mothers do a combination of breastfeeding and bottle feeding, thinking that infant formulas
26:03are more modern.
26:05Research shows that exclusive breastfeeding reduces the incidence of diarrhea as the mother's
26:10protective antibodies pass onto the baby through her milk.
26:14Breastfeeding is extremely important in relation to diarrhea, and actually we feel that this
26:21may be part of the reason why we are seeing so many children being admitted who are less
26:28than six months old.
26:30Actually only 4% of our mothers do complete breastfeeding for their children up to the
26:39age of six months.
26:41The majority use either artificial milk or both artificial and breastfeeding, which is
26:47a real problem because they don't have enough money to buy enough milk, and the second problem
26:53is that they mix it with contaminated water.
26:58Lack of clean water and sanitation are two of the main causes of illness, not only in
27:02Haiti but all over the developing world.
27:06It's estimated that 60% of people living in developing countries do not have easy access
27:11to safe drinking water.
27:14Many poor people pay up to one quarter of their incomes to purchase water.
27:19Often they must carry it some distance from the source, and it easily becomes contaminated
27:23without refrigeration and the tropical heat.
27:27100,000 people live in Sitesimone, one of the poorest sections of Port-au-Prince.
27:34Built on marshy lowlands, Sitesimone has no sewage system and raw waste runs in open channels.
27:41Yet in the midst of it all, there's a health care system that really works.
27:46Every resident of Sitesimone is registered with the clinic, and mothers and children
27:50are scheduled for monthly check-ups.
27:54Community workers called collaborators, like Maximilian Sanyas, visit families' homes to
27:59encourage parents to bring their children to the clinic.
28:03The main emphasis here is high coverage, health care for every resident, not just those
28:08who seek it out.
28:10The director of this program is a Lebanese-Haitian physician called Reginald Boulos.
28:17One of the most important factors of the success of this program has been the link between
28:22the collaborators and the population.
28:24Although we have 100,000 people living in five square kilometers, with the help of the
28:28collaborators serving each specific sector, we know exactly where each family lives, and
28:33we follow each family when they do not come for any type of health services.
28:39The first obstacle that we have was, first of all, to convince the people to come up
28:43and seek health care.
28:45This took us probably three to four years.
28:47And once we have achieved that, in terms of health service deliveries, I don't really
28:51believe that we have any problems.
28:53But I believe that health problem is always related to economic situation.
28:57Although we have improved the health status, these people are still poor, they still need jobs.
29:07Boulos has also gotten vocational programs going here, sewing and training in factory work.
29:14In the past 11 years, infant mortality in Site-Simone has dropped 60 percent.
29:21By analyzing health records, Boulos determined that the 3 percent of Site-Simone's children
29:26who were suffering from severe malnutrition were accounting for 62 percent of all infant deaths.
29:33By targeting these children for food supplements and their mothers for breastfeeding education,
29:39Boulos hopes infant mortality can be reduced even further.
29:44Site-Simone is widely regarded as a model program, and it shows that real improvement
29:49in health can be made even within a very poor environment.
29:57Three quarters of Haiti's population lives in rural areas with little access to health facilities.
30:03It's rugged territory with few roads and even fewer clinics.
30:08Nineteen-year-old Molly lives here in Grand Boucon.
30:12She's expecting her second child in four months' time.
30:16Molly's first child died a year ago after a long bout with diarrhea.
30:21This was before Molly learned about the availability of ORT.
30:26With this pregnancy, Molly is getting frequent prenatal checkups, and she hopes things will go better this time.
30:33Health rally posts are being organized in Haiti's countryside so that rural people will have a regular connection to health care.
30:40Mothers bring their children to be weighed monthly and keep track of their progress on a chart.
30:45The important concept is that a healthy child is a growing child.
30:50A special focus is on pregnant women.
30:53Here, Molly is getting immunized against neonatal tetanus,
30:57which claims a million newborn lives each year when the umbilical cord is cut without sterile procedure.
31:09The rally posts offer lectures on family planning as part of health education.
31:14Surveys show that 50% of Haitians want no more children than they already have.
31:20Up to 30% use no contraception, often because it is too expensive or they do not have access to where it is sold.
31:28Health educators explain the advantages of birth spacing and provide information on various forms of contraceptives.
31:38Lectures on ORT preparation are also given frequently.
31:46With increasing acceptance of ORT in Haiti, perhaps what happened to Molly's first child will not be repeated.
31:55Only one quarter of Haiti's rural population is now covered by the rally post system.
32:00Three million people remain to be served.
32:03But it's a start, and for Molly and many others, it's the difference between regular contact with a health system and no contact at all.
32:13Building on the success with ORT, Haiti will launch a nationwide campaign in the coming year to vaccinate all children under five.
32:22And prospects for Molly's baby are much improved over what they would have been a few years ago.
32:30The power of an idea which could stop a civil war was in evidence last spring,
32:34when the nation of El Salvador laid down its arms and stopped fighting for three days so that children could be immunized.
32:42Even higher than the casualty list of this bitter war was the number of children lost last year to immunizable diseases.
32:50President Jose Napoleon Duarte administered the first immunization, and the director of UNICEF was on hand to observe the occasion.
32:59This will mark a historic first for children everywhere in the world.
33:06For the first time in history, fighting and conflict around a country will have stopped just to help children.
33:18From the government, from the church, from all political factions are doing,
33:23is helping launch a campaign that is worldwide in scope, of which the Salvadorians are the symbol of hope for all mankind.
33:34Guerrilla leaders as well gave the immunization efforts strong support, providing publicity and encouragement for people to bring their children in.
33:43Cease fires were held on three separate days to enable the vaccinations to take place in safety.
33:50An estimated 300,000 children were immunized, reaching about three-fourths of the nation's goal of covering all children under three.
34:00The truce, reported to be highly successful, was arranged with the help of the Catholic Church.
34:06We came together to give a hug to a child, to see him cry, yes.
34:13To see him cry because he was given an injection or because he was given medicine, but to see him cry because we saved his life.
34:22Protecting children is an idea with powerful appeal, and heads of state around the world are beginning to realize its political potential.
34:31UNICEF has joined with the World Health Organization to work toward universal immunization of all the world's children by 1990.
34:39That goal is still remote, but the effort is gaining momentum.
34:43In 1985, we're now at the point where we see the possibility that if the world would truly organize itself,
34:51that by 1990 one could achieve a virtual universal immunization, saving more than four million lives a year.
35:00A leader in this effort is William Fagey, a veteran of the worldwide smallpox eradication campaign of the 60s and 70s.
35:08Smallpox was a simpler disease to control because it can be transmitted only by human contact with a victim.
35:15The present campaign requires immunizing every new child born.
35:20There are many difficulties in delivering immunization to people.
35:24For one thing, if a population doesn't really understand the benefits of immunization, they simply won't go out of their way in order to get immunized.
35:34One has to work around their schedule, the fact that they have to be in the fields, the fact that they have markets to go to, and so forth.
35:40There are many other barriers, though.
35:42The fact that some of these vaccines require two or three doses requires that you find the same people two or three times.
35:49And if some of the obstacles could be reduced by, for instance, developing a vaccine that requires only one dose,
35:55so that only one contact is required with a child, if that could be done, it would greatly simplify immunization.
36:02This is by far the most difficult element in the Gobi strategy.
36:06There are problems with keeping the vaccines cold and training workers to deliver them, not to mention paying for the effort.
36:14The costs are not totally known.
36:17Some people estimate it might be as much as $10 to $15 per child.
36:21We're talking about $1 billion to $1.5 billion a year for the entire third world.
36:28I should point out that this is less than is spent in this country each year just to advertise cigarettes,
36:35and that that entire portion would not be required from the developed world.
36:40It's estimated that less than a third of that money would be required from the developed world.
36:46International aid is helping many countries launch child immunization programs like El Salvador's.
36:52Colombia has reached 80 percent coverage.
36:55Thailand and Pakistan have achieved 60 percent.
36:58Sri Lanka and Indonesia are at 70 percent.
37:01Egypt has reached 60 percent.
37:03And Brazil has achieved 80 percent coverage.
37:06The developed world's annual contribution of $150 million needs to be tripled to meet the 1990 goal.
37:16In spite of success with immunizations, Brazil still has a vast need for improving its children's health.
37:22Here in the mountains of the northeast, in the small village of Pacatuba,
37:26it's not unusual for four children to die each week.
37:31Lidwina, 29, has lost one child and is struggling to keep the others healthy.
37:37Her husband is an unemployed construction worker.
37:40This year their income has been less than $200.
37:44Lidwina feeds her children rice and beans, which she grows in a small garden up on the mountainside.
37:50Meat is unheard of in the family's diet.
38:01The children attend school, but they miss a lot of classes due to frequent illnesses.
38:08Lauren, the eldest, is 11, but he looks about seven.
38:13Poor nutrition and frequent infections have stunted his growth.
38:17Bye, black people. Come back soon.
38:28Marilyn Nations, a medical anthropologist from the University of Virginia,
38:33has been working in Pacatuba for six years,
38:36trying to understand the problems parents face when children are sick.
38:48Are you going to sleep?
38:52With infant mortality so high in Pacatuba,
38:55young children are sometimes called little angels
38:58because their stay on earth is expected to be brief.
39:02Mothers say this does not make their leaving any less painful.
39:06Francesca has lost all the children she has had.
39:10She keeps their clothing in a cardboard box under her bed.
39:14Three weeks ago came the death of her only son, a year old.
39:45I love you so much.
39:51It's hard for a mother to lose a child.
40:02He died in my arms and in my heart.
40:05I miss him so much.
40:14I cry for my son almost every day.
40:18He was the only boy I had.
40:26He was so big, I missed him all the time.
40:31How old was he?
40:34He was eight.
40:37I never cried. I cried because I didn't want to die.
40:40But I cry more. I cry every day.
40:48If their children seem desperately ill,
40:51mothers may bring them here, to this rehydration center in Fortaleza.
40:55It's a long and costly trip,
40:58and Nations has watched children die in line while waiting for care.
41:03Many children here are severely dehydrated.
41:06A common symptom is the sunken fontanelle on top of the child's head.
41:11This center still uses mainly IV rehydration.
41:14Administrators here have been slow to change over to ORT.
41:18In the course of interviews with mothers,
41:21Nations has learned that they go to considerable lengths
41:24to cure their children's diarrhea before coming here.
41:27Some Western physicians think that poor rural mothers
41:30wait until their children are half-dead to take care of them,
41:33but what I found in my research is quite the contrary.
41:36Mothers very early in the episode have taken their children
41:39to an elaborate network of traditional healers to treat their diarrhea.
41:43They are the praying women, the hesederas,
41:46or other spiritualists, herbalists, who exist in the community
41:50and who have great experience in treating enteric diseases.
41:55Donna Binio is one of Pocatuba's hesederas, or praying women.
42:04People in Pocatuba share a strong belief
42:07that diarrhea is caused supernaturally
42:10by a sudden fright, evil eye, or spirit intrusion,
42:13as well as by unclean water and lack of sanitation.
42:19It's believed that a supernaturally caused illness
42:22can only be cured by a healer with supernatural powers.
42:26Realizing that hesederas are the first to be consulted
42:29when children are sick, Maryland Nations devised a plan
42:32whereby these traditional healers have become the dispensers
42:35of ORT in Pocatuba.
42:38She is developing the project as a model for other communities,
42:41where the traditional healers provide the first line of defense
42:45against diarrhea.
42:47Traditional healers have the respect of the community.
42:50They know these children. They see them every day.
42:53They know how to measure the solutions correctly,
42:56partially because of their long training
42:58in preparing traditional remedies.
43:00They don't charge.
43:02They do this for the good of the people in the community.
43:05And probably most important,
43:07they're sought very early in the illness episode,
43:10before the child gets severely dehydrated.
43:13The people of Pocatuba met together
43:16and voted to build an ORT curing room
43:19for hundreds of the town's hesedera healers.
43:22This project marries traditional and western medicine
43:25and has been successful so far
43:27because it has the support of the community.
43:30But it is only one pilot project.
43:33A strong need for ORT remains
43:36in other villages of northeast Brazil.
43:39In the coastal city of Fortaleza, 20 miles away,
43:42refugees from the poverty of rural life
43:45live in urban shantytowns called favelas.
43:48Maria Osiliadora de Souza is a Brazilian physician
43:52who grew up in a poor family in Brazil's interior.
43:56She visits this favela each week,
43:59teaching mothers how to do ORT.
44:02Janjira washes clothes for a living.
44:05She has had 22 children, 16 are living.
44:08When the rains come, the clothes won't dry,
44:11and Janjira doesn't get paid,
44:13so she goes begging to put food on the table.
44:17Mothers here often have children starting in their teens
44:21and continuing well into their 40s.
44:24Such pregnancies often result in low birth weight babies
44:28who are in turn more vulnerable to diarrheal illnesses.
44:32ORT has brought improvements here,
44:35but it only treats the symptom of a much larger problem.
44:43It depends on the water, on the garbage,
44:46on the lack of food, on the lack of unemployment,
44:50especially from parents.
44:52It depends on a number of things,
44:55and all of this leads to diarrhoea.
44:58So the relationship between the economic and the health
45:02is very close, and we can't separate it.
45:05Dr. Souza meets with the favela women
45:08to discuss ORT and family health problems.
45:12Breastfeeding is sometimes difficult for women like Marluce,
45:16who don't themselves get enough to eat.
45:41I don't take anything.
45:43If I had taken to avoid it,
45:46if I had taken to avoid it,
45:49I wouldn't have had 13 girls.
45:52Now I think it's too much to raise myself.
45:57If I hadn't taken care of her, she would have been with someone else.
46:01I can't help you.
46:03Gracia is 17, Jandira is 22.
46:09Vera is 10.
46:12I think it's easier to have a boy.
46:17What do you think about raising a child?
46:22It's difficult to raise a child.
46:25It's difficult to raise a child, to educate a child.
46:28We can't educate a child.
46:31Not even Kiko can teach a child.
46:34I value education.
46:37Nearly all of the women at the meeting expressed a need for birth control.
46:41Jandira was the lone dissenter, saying,
46:44I will bear as many children as God sends me.
46:48Children born less than two years apart run twice the risk of dying
46:52as children spaced further apart.
46:56A complex set of reasons includes a higher risk of low birth weight,
47:00poor maternal health,
47:02and a reduction in the time and resources parents can devote to a child.
47:06Favela husbands are often away looking for work.
47:09So many households are run by women.
47:12The key to change in the developing world is the woman.
47:16The family will not change unless woman as mother
47:20is given the information, the empowerment she needs to manage the family
47:24because she is really the manager of a family.
47:26If 50% of the world's population were women,
47:30if they are ignored, if they are pushed aside from the mainstream of social life,
47:35then the whole of society suffers.
47:38So the problems of women's degradation,
47:40of women's liberation, if you like,
47:43of the status of women,
47:45is not only a problem for women.
47:47It's a whole human problem.
47:50It must concern men as well as women.
47:53One of the factors most highly correlated with child survival
47:57is the educational level of women.
48:00Two-thirds of women in developing countries are illiterate,
48:03and it is often difficult to convince them
48:05that simple, low-tech measures like ORT and breastfeeding can be effective.
48:11Spacing births is also very important to child survival.
48:15But for many poor women, contraception is too expensive,
48:18and family planning services have tended to be kept separate from health care.
48:23Family planning really ought to be a completely integral part of health services
48:28and a very important part of health services.
48:30It's really just an accident that they grew up separately.
48:34In fact, family planning has to do with very sensitive issues in society.
48:40It has to do with morality and sexual behavior and desires for childbearing.
48:46And so it was considered an area too touchy for the health profession
48:52and too touchy for governments to get involved in.
48:56Family planning has always evoked controversy,
48:59especially in the developing world.
49:02But at the 1984 World Population Conference in Mexico City,
49:06most developing nations agreed that stronger family planning programs are needed.
49:11Then the American delegation shocked the assembly
49:14by suggesting that population is a neutral factor in nation's development
49:18and that rather than hindering progress, in some cases population growth promotes it.
49:24The U.S. also said it would withdraw financial aid from many international groups
49:29that include abortion and their family planning programs.
49:33In this highly charged context,
49:35it's not surprising that UNICEF has largely left family planning to another U.N. agency,
49:41the Fund for Population Activities.
49:45Why have population so-called control programs, population control programs,
49:52petered out?
49:55Most of them have petered out
49:57because they take the supply approach
50:00as though the supply of contraception
50:04will persuade people to demand contraception.
50:07It doesn't happen.
50:08Supply does not create demand.
50:12What creates demand is self-interest.
50:15Understanding of how necessary it is for myself, my children, my husband, my wife,
50:22what benefit a certain course of action will be to us.
50:27Then demand is created.
50:31Demand is generated.
50:33The whole population movement will not succeed
50:36until people realize,
50:38the programmers, the planners realize
50:41that the population problem
50:44will never be solved in the uterus,
50:46but in the human mind.
50:49Many people are deeply concerned
50:51about the explosion of population
50:53attendant upon the fall in mortality throughout the world.
50:57The thing that they don't realize quite so well
51:00is that when we look within developing countries,
51:02the people who are having small families
51:04are those who have a certainty
51:06of adequate health care and opportunity for education,
51:09have some hope for their children's future.
51:12By providing the virtual guarantee
51:15of good health for a child,
51:17families begin to talk about limiting their own fertility
51:20for their own reasons.
51:22They don't want too many,
51:23but they certainly are very anxious to have enough children.
51:26Enough is increasingly recognized to be fewer and fewer,
51:30provided, of course, they know they will survive.
51:33In every country, Western and developing alike,
51:36fall in fertility has only come after fall in mortality.
51:42The question remains for some developing nations,
51:45how long will that transition take?
51:47Runaway population growth has joined with poverty and drought
51:51to create a nightmare of famine in Africa.
51:54Environmental resources are at the breaking point,
51:57with food production lagging behind
51:59the fastest population growth rates the world has ever known.
52:03Infant mortality is highest here as well.
52:06Rapid population growth is such an important problem,
52:09it bears on many aspects of human life.
52:12If you care about health, prevention of starvation, illiteracy,
52:16we're never going to eliminate these problems
52:18unless we implement strong family planning programs.
52:22Events in Africa pose the most difficult challenge
52:25to UNICEF's strategy, for severely malnourished children
52:29are the most vulnerable to disease.
52:32Shortage of food may be one cause of their weakness,
52:35but what carries the children away to death in the end
52:38is usually diarrhea or infection.
52:41One child in four dies within the first year of life.
52:46Clearly, the needs in Africa are the most desperate.
52:50UNICEF has made that continent its top priority,
52:53but GOBI programs here still have the longest way to go.
52:57In other places around the world, the progress is encouraging.
53:01120 UN member nations are promoting programs
53:04using GOBI interventions.
53:06Seventy countries are launching national ORT campaigns
53:10to control diarrhea.
53:12176 nations have begun vaccination efforts
53:15against the six major childhood diseases.
53:18Still, it's estimated that only about one-third
53:21of the world's children are protected at present.
53:24Money will be important to GOBI's success.
53:27Even more important will be social and political will.
53:31One of the most encouraging developments
53:34of the last 40 years is that the world can today
53:39be expected to respond to a loud emergency
53:44if there is a major drought as we see in Africa.
53:48Today, we can expect that the world community will respond
53:52and that the publics of the world will insist
53:55that governments do something about this.
53:58We have not yet developed a comparable ethic
54:01that deals with the silent emergency,
54:04the far larger toll that comes from people caught
54:07in this conjunction of poverty and gross underdevelopment.
54:10Now we have an opportunity to save millions of lives,
54:15to improve the health of hundreds of millions of children.
54:18We need a new ethic that says
54:20we must take advantage of this opportunity.
54:23There are so many problems in this world
54:25that we can't really affect.
54:27But when we can do something,
54:29as with the vaccine-preventable diseases,
54:31when we can prevent 5 million deaths a year,
54:34when we can prevent 5 million cases of crippling,
54:37then we have an obligation to do that.
54:39It's simply unacceptable for the world to allow this to continue.
54:43One measure of civilization is how well do we treat
54:46the most vulnerable members of our society.
54:49In this case, we're talking about the most vulnerable members
54:52of the global village that we all live in.
54:55UNICEF's child survival effort is off to a promising start,
54:59but there are still many obstacles to overcome.
55:03Its ultimate effectiveness will depend on raising money,
55:07public awareness, and political will to carry it through.
55:12The GOBI strategy will succeed only if there is a dialogue
55:16between health planners and developing nations themselves,
55:20for experience shows that a program
55:23without the support of the people it serves is bound to fail.
55:28UNICEF may be right in its contention
55:30that improving child survival
55:32will eventually bring lower birth rates.
55:35The experience of MATLAB seems to bear out this idea.
55:39But there must also be a clearer understanding
55:42of the important role of families' fertility plays
55:45in the prospects for children's health.
55:48This realization must come both at the level of individual families
55:53and at the level of nations,
55:55for in the end, the destinies of societies and their children
56:00cannot remain separate.
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58:03© transcript Emily Beynon