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.
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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