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CHILD
SURVIVAL
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Risks and the Road to Health
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DEMOGRAPHIC
DATA FOR
DEVELOPMENT
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Child Survival:
Risks and the Road to Health
Library of Congress Cataloging in Publication Data
Galway, Katrina, 1955Child Survival.
“Prepared for the Agency for International Development, Office
of Population and Office of Health by the Institute for Resource
Development at Westinghouse.”
“March 1987.”
Bibliography: p.
1. Children—Diseases—Developing countries—
Statistics. 2. Children— Health and hygiene—
Developing countries. 3. Child health services—
Developing countries. I. Wolff, Brent, 1959-.
II. Sturgis, Richard, 1936-, III. Institute
for Resource Development at Westinghouse (Columbia,
Md.) IV. United States. Agency for International
Development. Office of Population. V. United States.
Agency for International Development. Office of Health.
VI. Title. [DNLM: 1. Developing Countries, 2. Health.
3. Infant, Mortality. 4. Infant, New Bom, Diseases.
5. Probability. WA 900.1 G183c]
RJ103.D44G35 1987 362.1’9892’00091724021 86-34280
Slide reproductions of the figures used in this report, a
microcomputer diskette copy of the 10 appendix tables,
and multiple copies of this report are available upon
request. Refer to the order form on the inside back cover
of this report.
Child Survival:
Risks and the Road to Health
Prepared by
The Demographic Data for Development Project
Katrina Galway
Brent Wolff
Richard Sturgis
Institute for Resource Development/Westinghouse
March 1987
Acknowledgments
A report prepared for the Agency for International Development
Office of Population and Office of Health
by the Institute for Resource Development/Westinghouse.
This report was supported by the United States Agency for International Development
(AID), through Demographic Data for Development Project Contract No. A1D/DPE3000-C-00-2017-00, and IQC Contract No. PDC-1406-1-11-4062-00 at the Institute for
Resource Development/Westinghouse. Support for printing was provided by the Academy
for Educational Development (AED). The contents of the report do not necessarily reflect
the views or policies of AID, AED, or Westinghouse.
The authors express appreciation and special thanks to many colleagues who contributed
to this report. Alfred Buck, Neal Halsey, and Henry Mosley gave early guidance in the
development of the report. Pamela Johnson, Coordinator for Child Survival, Office of
Health at AID, gave early guidance and continued to provide assistance throughout the
production of the report. The valuable assistance of the following reviewers is also appre
ciated: Brigitta Bucht on the projections; Robert Black on the Diarrheal Disease section,
Sandra Huffman on the Malnutrition section, Deborah Maine on the High Risk Fertility
section, and Eugene McJunkin on the Water and Sanitation section. Advice and technical
support were provided by John Haaga for child malnutrition estimates, Carol Chan of
the Expanded Programme on Immunization of the World Health Organization (WHO)
and Sydney Moore of the Population Information Program on immunization statistics,
and James Tulloch of the Programme for the Control of Diarrheal Diseases of WHO on
diarrheal disease estimates. The authors gratefully acknowledge the assistance of Phyllis
Avedon for editorial support; Shea O. Rutstein for technical support, and Caroline Sturgis
for graphics support. Staff members of the Population Policy Development Division of
AID, where the Demographic Data for Development Project is located, gave support and
direction to the report, especially John Crowley and Judith Seltzer. Persons associated
with the Office of Health of AID also provided periodic assistance, in particularJack Lawson
and Sally Stansfield. Valuable assistance was also received from the staff of the Demographic
Data for Development Project: David Cantor, Alene Gelbard, Nancy McGirr, Joseph Regan,
and Jane Weymouth.
- SOCHASA^
Koramangala
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V^^Bangalore - 34^
CHHoo NVI
I
Editors Note:
Infant and Child Mortality Rates
This report clarifies the presentation and interpretation of infant and child mortality rates
in two ways: first, mortality rates are reported as percentages. Second, child mortality
rates are reported as the percentage of children bom who die between exact ages 1 and
5. Because the denominator for both rates is the same, infant and child mortality rates
are additive, i.e., adding infant mortality rates to child mortality rates provides percen
tages of children bom who die before age 5.
1
CONTENTS
PAGE
World Patterns and Rates of Child Survival
.1
Major Impediments to Child Survival and
Strategies for their Removal
9
I
II
Diarrheal Disease
10
m Vaccine-Preventable Diseases
16
IV Acute Respiratory Infection
22
Malaria
25
VI Malnutrition
31
VII High-Risk Fertility Behavior
39
Socioeconomic Factors and Child Survival
45
Vm Education and Literacy
46
IX Availability of Modem Health Services
51
V
X
Income Per Capita and Government Expenditures
54
XI Food Availability
56
XII Water Supply and Sanitation Facilities
59
Child Survival Summary Chart
61
Selected Bibhography
65
Appendices
PAGE
Appendix 1: Child Survival Statistics
I
75
Table 1: Numbers of Infants and Children Age 1-4 if 1980-85 Mortality
Levels Continue
76
Table 2: Percent and Numbers of Children Dying before Age 1 and Age 5
if 1980-85 Mortality Levels Continue
78
Table 3: Numbers of Infants and Children Age 1-4 if Mortality Levels
are Reduced to Reach Year 2000 Goals
80
Table 4: Year 2000 Goals for Reduced Infant and Child Mortality, and
Numbers of Children Dying before Age 1 and Age 5 if Mortahty
Levels are Reduced
82
Table 5: Country Populations and Basic Demographic Indicators
84
Table 6: Women of Reproductive Age, Fertility Rates, and Births
86
Table 7: Immunization and Health
88
Table 8: Nutrition: Breastfeeding, Percent Malnourished, and Food
Production Per Capita
90
Table 9: Education Indicators
92
Table 10: Economic and Water and Sanitation Indicators
94
Appendix 2: Methodology of Projections
97
Appendix 3: Definitions and Sources of Data
98
Appendix 4: Countries and Regions
101
I
List of Figures
Figure 1-A
Figure 1-B
Figure 1-C
Figure 2-A
Figure 2-B
Figure 2-C
Figure 2-D
Figure 2-E
Figure 2-F
Figure 3-A
Figure 3-B
Figure 3-C
Figure 3-D
Figure 3-E
Figure 4-A
Figure 4-B
Figure 5-A
Figure 5-B
Figure 5-C
Figure 5-D
Figure 6-A
Figure 6-B
PAGE
...6
Percent of Total Population Under Age 5 by Region
Numbers of Children Under Age 5 by Region at 1980-85
Mortality Levels and at Goals for Year 2000 Reduced Mortality
6
Levels...............................................................................................
Number of Child Deaths at 1985 Mortahty Levels and at
7
Reduced Mortality Levels
Diarrhea Mortahty as a Proportion of Mortality from All Causes:
.10
Rural Bangladesh
Estimated Annual Episodes of Childhood Diarrhea and Average
Number of Days of Diarrheal Illness—Developing Regions and
11
Selected U.S. Example
12
Estimated Median Diarrheal Episodes Per Year by Age
13
Oral Rehydration Solution
14
Estimated Access and Use of ORT in Developing Regions
Impact of Hygiene Education on the Incidence and Duration of
15
Diarrheal Illness: Guatemala
Annual Child Deaths from Vaccine-Preventable Diseases and
Deaths Prevented by Immunization in Developing Countries
16
Neonatal Mortahty With and Without Health Intervention
17
Measles Case Fatahty Rates by Age—Percent of Infected
Children Who Die From Measles—West Africa
18
Immunization Coverage by Region—Percent of 1-Year-Olds Fully Immunized 19
Immunization Coverage and Incidence of Immunizable Diseases
for Selected Developing Countries, 1974-1984
20
Acute Respiratory Infection Mortahty by Nutritional Status—
Phihppine Hospital Cases
23
Incidence of Acute Respiratory Infection Among Children With
and Without Ocular Symptoms of Vitamin A Deficiency:
24
Indonesia
The Life Cycle of Malaria
25
Impact of Malaria Control on Infant Health and Survival:
Comparison of Treated and Untreated Villages in Kenya,
1970-1973
27
Global Trends in Malaria: Number of Cases Reported, 1974-1984
28
Regional Trends in Malaria: Number of Cases Reported,
1974-1984
29
Risk of Death by Nutritional Status: Children Age 1-36 Months
31
Infant Mortahty by Birth Weight
32
Figure 6-C
Figure 6-D
Figure 6-E
Figure 6-F
Figure 6-G
Figure 6-H
Figure 7-A
Figure 7-B
Figure 7-C
Figure 7-D
Figure 7-E
Figure 8-A
Figure 8-B
Figure 8-C
Figure 8-D
Figure 8-E
Figure 8-F
Figure 9-A
Figure 9-B
Figure 10-A
Figure 10-B
Figure 11-A
Figure 12-A
Regional Patterns of Acute Protein-Calorie Malnutrition
Estimates of Childhood Malnutrition in Developing Regions,
1980.................................................................................................
Percent Low Birth Weight: U.S. and Developing Regions, 1982
Mortality for 3 Different Time Periods During First Year of Life
By Source of Milk: Rural Chile
Impact of Breastfeeding Promotion: Two Examples from
Costa Rica
The Road to Health: Model Growth Chart
Percent of Births Close to Another Birth
Percent of Children Who Die Before Age 5, When Births are
Spaced at Least 2 Years Apart, and When a Preceding and/or
Following Birth Occurs Within 2 Years
Relative Mortality Levels of Children Bom to Mothers of
Different Ages
Percent of Women Age 20-24 Who Had at Least One Birth as a
Teenager
Relative Mortahty Levels of Children by Birth Order
Pattern of Association Between Percent of Women Literate and
Percent of Children Dying Before Age 5
Mortality of Children Age 1 - 4 According to the Educational
Attainment of their Mother or Father, Peru 1977-78
Mortahty of Children Age 1-5 of Mothers with No Education,
and Mothers with at Least Primary School Education
Percent of Adult Women Who Ever Attended School,
Distributed by Highest Level Ever Attended: Kenya 1979
Percent of Men and Women Who Can Read and Write
Percent of Boys and Girls Who Attended Primary School in
1970 and 1980-84
Health Expenditures and Population Served
Utilization of Health Services According to Travel Distance
Pattern of Association Between Gross National Product Per
Capita and Life Expectancy
Percent of Government Expenditures Developing Countries
Spend on Health, Education, Housing, Social Services and
Welfare, and Defense
Percent of Children Dying Before Age 1 and Per Capita Calorie
Availability: Sri Lanka, 1950-80
Percent of Population with Access to Safe Water and Sanitation
Facilities
PAGE
33
34
35
36
37
38
39
39
40
41
42
.46
47
47
48
49
49
51
52
54
55
56
59
(
List of Maps
Map 1A
World Child Mortality Rates
PAGE
...8
Map 5A
Epidemiological Assessment of Status of Malaria, 1984
26
Map 11A 1983 Per Capita Food Production as a Percent of 1969 to 1971
Production
57
List of Fact Sheets
PAGE
Fact Sheet 1
A:
Child Mortahty and Numbers of Deaths by Region
Deaths of Children Under Age 5 as a Percent of All Deaths,
B:
C:
1985 ...........................................................................................
Percent of Deaths Occurring in Each Region, 1985
Percent of Children Dying Before Age 1 and Before Age 5
3
3
3
Fact Sheet 2
A
B
C
D
Births by Region
Percent of World Births Occurring in Each Region...............
Number of Births During 1985-2000.....................................
Average Number of Children Women Bear
Number of Women of Reproductive Age, 1985-2000
4
4
4
4
Fact Sheet 3
A:
Geographic Inequahties in Child Mortahty
Mortality of Children of Urban, Educated, Professional
Parents, and of Rural, Uneducated, Agricultural Parents
Percent of Children Dying Before Age 5: Range and Average
for Regions and Selected Countries........................................
Percent of Children Dying Before Age 5: Range and Average
for Rural and Urban Areas of Selected Countries
B:
C:
5
5
5
List of Tables
PAGE
Table 7A
Percent of Married Women Age 15-44 Who Do Not Want to
Become Pregnant and Who Know About and Use Contraception
Table 12A Reduction in Diarrheal Morbidity Rates Attributed to
Improvements in Water Supply or Excreta Disposal
43
60
World Patterns and
Rates of Child Survival
M WORLD PATTERNS AND RATES
OF CHILD SURVIVAL
A child bom in one of the high-mortality African and Asian
countries today is on average 20 times more likely to die
before reaching age 5 than a child bom in the United States,
Japan, or Sweden. The “accident” of geographic location of
birth—and the risk of dying that accompanies this accident
—have little or nothing to do with genetic inheritance and
nothing at all to do with choice by the child. The level of
childhood mortality in developing countries signals both
alarm and opportunity: alarm because of the startlingly
greater risk of death children face in these countries; oppor
tunity because we have the means at hand to dramatically
reduce childhood mortality.
The scarcity and uneven distribution of health facilities
and services and the marginal economic and human re
sources that invite infant and childhood disease occur
within distinct world and country boundaries, as shown in
Fact Sheet 1. Of every 100 children bom in Africa, 12 die
before age 1; 10 of every 100 infants die in Asia, 9 in the
Near East, and 6 in Latin America and the Caribbean. In
Japan and Sweden, by contrast, fewer than 1 percent of
newborns fail to reach their first birthday. The U.S. rate is
slightly higher than 1 percent; the average for all developed
countries is closer to 2 percent. The death of a child, a
relatively rare tragedy for parents in developed countries,
is a frequent occurrence in the developing world. In Egypt,
for example, two-thirds of women experience the death of
one or more children by age 50.
In 1985 there were 570 million children under 5 in the
world, a total higher than the population of the African
continent. They account for almost 12 percent of the
world’s total population, as seen in Figure 1-A. During the
15 years between 1985 and 2000, approximately 2 billion
children are projected to be bom. Of this number, 87 per
cent (1.8 billion) will be bom in the developing world. At
1980-85 levels of infant and child mortality in these coun
tries, 240 million of these children can be expected to die
before age 5. If mortality levels were instead comparable to
those of developed countries, 87 percent, or 207 million of
these children, would live. This is a child population almost
as large as the total number of inhabitants in 1985 of the
United Kingdom, West Germany, France, and Poland.
The wide variations in risk of death between developed
and developing regions are also seen within regions. While
nearly 20 percent of all African children die before reaching
age 5, this proportion rises to 31 percent in Sierra Leone
and falls to a relatively low 13 percent in Zimbabwe. Varia
tions among countries within world regions are shown in
Fact Sheet 3.
2
Large differences in levels of childhood mortality often
occur within tire same country. Regional differences within
countries are often as large or larger than those between
countries and world regions. Consistent differences are
found both between urban and rural areas of countries and
among the urban and rural areas themselves. As shown in
Fact Sheet 3, the risk of dying before age 5 in a rural area can
be twice that of an urban area in the same country. Further,
the highest mortality levels found in urban areas within a
country are often higher than the levels of better-off rural
areas.
These dramatic differences in levels of infant and child
hood mortality underlie worldwide concern for the tremen
dous inequities in children’s opportunities to survive and
be healthy. Yet these geographical inequities are in one
sense cause for hope. Although a country may be located
in a developing region, it does not necessarily follow that
it will have high child mortality rates; some countries in
each region already have relatively low rates. Moreover,
varying rates within countries indicate that low childhood
mortality can and is being achieved.
The major impediments to child survival have been
identified, as have many strategies for removing these im
pediments. Infectious and parasitic diseases, malnutrition,
and the risks associated with high levels of fertility are the
major obstacles. Because they flourish in poverty, lasting
solutions to these problems may require long-term socio
economic development. Nonetheless, for every major im
pediment to child survival, we now have the means, within
current resources, to rapidly and dramatically reduce the
terrible burden of illness and death on the world’s children.
Among the most effective are oral rehydration therapy,
mother and child immunizations, and wider spacing of
births, which can save millions of lives and prevent untold
suffering in developing countries between now and the end
of the century.
MORTALITY REDUCTION TARGETS
Increased understanding of the various impediments and
the possibilities for their removal, heightened by the
remarkable achievements of child survival projects in
various countries, is stimulating national and international
efforts to lower childhood death rates. Of the various targets
for reductions in infant and child mortality by the year
2000 that have been suggested, this report uses the follow
ing: In countries where rates of infant mortality are above
12.5 percent, the target is to reduce this number to 7.5 by
Fact Sheet 1 — Child Mortality and Numbers of Deaths by Region
I
A: Deaths of Children Under Age 5
as a Percent of All Deaths, 1985
B: Percent of Deaths Occurring In Each Region, 1985
Children Age 1-4
Infants
Developed
Latin America Countries
& Caribbean
53
48
Africa
^\2.9
7.7 \
42
China
China ^\8.9
6.1 \
Africa
25.3
7.7
34
Developed
Latin America Countries
& Caribbean .8
30.9
6.7 'Near
49.2
East
47.7
7.3
15
Asia*
Africa
Near East
Asia*
China
Asia’
10 million infants
died during 1985
3
Latin
Developed
America & Countries
Caribbean
The 11.9 percent of world's population under age 5 contributed almost
one-third of all deaths.
Near
East
5 million children
age 1-4 died during 1985
Mortality during the first year of life exceeds mortality during ages 1-4.
Globally, there are approximately 2 infant deaths for each death of a
1-4-year-old. Higher levels of overall mortality are associated with
proportionately higher levels of child mortality. In Africa, the ratio of
Infant to child deaths is 1.6 to 1; in developed countries the ratio Is 6.6 to 1.
C: Percent of Children Dying Before Age 1 and Before Age 5
1980-85 Mortality Level
Goal for Year 2000
Reduced Mortality Level
2] Percent dying by age 1
| Percent dying by age 5
| Percent dying by age 5
|
§ Percent dying by age 1
19.7
15.4
13.4
11.9
10.1
9.3
8.8
6.3
6.3
5.6
4.5
3.9
Near East
Asia’
China
f 3.9
3.2
1.6
Africa
4.8
2.0
1.8
Latin
Developed
America & Countries
Caribbean
Africa
Near East
Asia’
2.3
China
0.8 0.9
Latin
Developed
America & Countries
Caribbean
Goals for reduced mortality would still not bring levels of child mortality in developing regions to 1980-85 levels of mortality In developed regions.
’Excluding China
Source: Dato are included in Tables 1,2,3, and 4 of Appendix 1.
Demographic Data for Development Project
3
Fact Sheet 2 — Births by Region
I
B: Number of Births During 1985-2000
(in thousands)
A: Percent of World Births Occurring in Each Region
Developed
Countries
268,073
1995-2000
1990-1995
1985-1990
Latin
America &
Caribbean
194,314 /
36.1
—135.1
7133.5
----------------
13.1%
Africa
402,513
19.7%
9.5%
CT
<D
04
21.7
£
c
Near East
152,509
7.5%
19.6
15.3%
OT
15,315.215.3
S
2
China '
312,163
34.9%
o
5
o
5
Asia*
711,838
Africa
Near East
Asia'
Latin
America &
Caribbean
China
Developed
Countries
Including China, more than 50 percent of the world's children are
projected to be born in Asia between 1985 and 2000. Due to an
increasing number of women of childbearing age and high birth rates,
the percentage of the world's children born in Africa is expected to
increase rapidly.
More than 2 billion children are projected to be born in the world
between 1985 and 2000. Some 87 percent, or 1.8 billion, will be born in
developing countries.
D: Number of Women of Reproductive Age:
1985-2000 (in millions)
1985
2000
1995
1990
C: Average Number of Children Women Bear
503
453
404
<A
6.6
346
334—
357
>-5
312
a>
in
a>
CT
5.1
4,2
312
309
302
276
<
3.9
5
E
o
2.2
141
127«
2.0
1l2ri
991- ;
92
Africa
Near East
Asia-
China
Latin
Developed
America & Countries
Caribbean
Fertility of women in developing countries is almost twice that of women
in developed countries. In some African countries women bear enough
children to replace their generation fourfold, while in some European
countries and the United States, fertility is below replacement level.
’Excluding China
Near East
Asia’
China
Latin
America &
Caribbean
The number of women of reproductive age will increase through the end
of the century, reflecting momentum from higher birth rates In the past.
As a result, the total number of births occurring each year Is projected to
grow, despite overall declines in fertility taking place in all regions of the
world.
Source: United Nations (Data are included in Table 6 of Appendix 1.)
Demographic Data for Development Project
4
I
Developed
Countries
I
Fact Sheet 3 — Geographic Inequalities in Child Mortality
J
A: Mortality of Children of Urban, Educated, Professional
Parents and of Rural, Uneducated, Agricultural Parents
I — I Mortality of children of
1 —
urban, educated,
professional parents
B: Percent of Children Dying Before Age 5:
Range and Average for Regions and Selected Countries
34.0,-
Increased mortality of
children of rural uneducated,
agricultural parents
I
31.°-=
Highest country
■ *■
Regional average
1
Lowest country
22.5—
Senegal
I
19.7-i-
Peru
Nepal
19.5bs=i
J.
| 15.4-
13.4-H-
Bangladesh
Kenya
j.s-
8.8- ■■
Haiti
Pakistan
Indonesia
1.7
Sudan
1.2
III
1.9- y-
18l
1.3'
Colombia
Mexico
Atrica
Near
East
Panama
14.7 16.2
Lesotho
Asia’
.9— .8
Latin China Devel- United Japan Sweden
America &
oped States
Caribbean
Countries
The range of national child mortality levels within each region is very
wide. It is notable that all regions have at least 1 country with mortality
below 2 percent, and that mortality is never above 25 percent in the Near
East, and Latin America and the Caribbean.
’Excluding China
Thailand
Philippines
Costa Rica
Source: UNICEF (Dafa are included in Table 2 of Appendix 1.)
Jordan
Korea
Syria
C: Percent of Children Dying Before Age 5:
Range and Average for Rural and Urban Areas
of Selected Countries
Guyana
Sri Lanka
0urban
Trinidad & Tobago
Highest Area
[] Rural
National Average
Malaysia
Lowest Area
Jamaica
0
PF* 30
5
10
15
20
25
30
Percent Dying Before Age 5
27==,
23—
"
23
’
w-23
-23
21-
The risk of death for a child is associated not only with urban or rural
residence, but very importantly with the education and work status of his
or her parents. Mortality levels of children of urban, educated,
professional parents are often less than one-fourth of those of rural
children with less educated parents working in agriculture.
LLi9
13^
^19
13“
16'
16
U=16
— 15
14
12
Source: Hobcroft, J.N., J.W. McDonald, S.O. Rutstein "Socioeconomic Factors in Infant and Child
Mortality: A Cross-National Comparison," Population Studies, 38(2), table 14,1984.
10
9
7
9
.8 9H
5
Benin
Egypt
Peru
Kenya
Thailand
Srl
Lanka
Within countries, different regions experience different levels of child
mortality. Generally, mortality in urban areas is lower than in rural areas.
Source: Unpublished World Fertility Survey data, Tech. No. 2364, courtesy of S.O. Rutstein.
Demographic Data for Development Project
5
Figure 1-A
Percent of Total Population
Under Age 5 by Region
18.9
World Average, 11.9
Ij -1
15.8
I
_V_
I
o 1
13.9
8.8
7.5
1
Latin
Developed
America & Countries
Caribbean
Asia*
Near East
Africa
Nearly 12 percent of the world population in 1985 consisted of children
under 5 years of age. In Africa, about 20 percent of the population, or 1 In
every 5 persons, was under age five.
’Excluding China
Source: Tables 1 and 5 of Appendix 1.
Demographic Data for Development Project
the year 2000. Current rates of 10.0 to 12.5 percent are
targeted to fall to 5.0, and where rates are below 10.0 the
goal is to halve the current rate. These targets are the basis
for projecting the numbers of children likely to survive,
based on continuing the 1980-85 mortality rates and
achieving the improved targeted rates (a discussion of the
methodology appears in Appendix 2).
Estimates of the number of children who would live,
based on year 2000 target rates, are shown for each country
in Appendix 1. The numbers of additional children that
would survive within each region of the developing world
are shown in Figure 1-B. During the year 2000 the death toll
would be cut by 3.3 million children in Africa, 684,000 in
the Near East, 3.8 million in Asia (excluding China), and
586,000 in Latin America. If China is included, the total
number of children whose lives would be saved in devel
oping countries exceeds 8.9 million; a number greater than
the 1985 population of Sweden. These numbers are illus
trated in Figure 1-C.
6
A MODEL OF CHILD SURVIVAL
Why do so many children die? There is no simple answer.
Disease and malnutrition cause millions of children to die.
Is cutting the death rate then essentially a matter of prevent
ing disease and malnutrition? Many agree that this approach
is sound, but others argue that it tends to ignore the social
Figure 1-B
Numbers of Children Under Age 5 by Region
at 1980-85 Mortality Levels and at Goals for Year 2000 Reduced Mortality Levels (in millions)
Number of children If mortality Is reduced to reach year 2000 goals
] 1985
[
11990
|
] 1995
2000
1995
2000
Number of children if mortality remains at 1980-85 level
I l"0
|
] 1985
220 221
212#H^-j
141
121
102
97 101
86
<5
■g
103
93 96 99
49
86
41
Africa
•Excluding China
Source.- Tables 1 and 3 of Appendix 1.
88 88 88 88
56 |9
62 63
88 88 88 87
56 59
46 46
Near East
105
Asia’
China
Latin America
& Caribbean
Developed
Countries
Demographic Data for Development Project
I
6
►
i
I
J
i
Figure 1-C
Number of Child Deaths at 1980-85 Mortality Levels
and at Reduced Mortality Levels (in millions)
Child deaths at 1980-85 mortality level
| 1985
|
] 1990
|
] 1995
2000
1995
2000
Child deaths at reduced mortality level
| 1985
|
i
] 1990
7.3
J
7.3
7.3
6.0
5.4
6.1
4.7
4.1
4.1
3.9
1.2
1-3
1.4 14
1.1 1.1 1.2 1-2
1.1 1.2 1.2
2.7
Africa
Near East
Asia’
‘Excluding China
Source: Tables 2 and 4 of Appendix 1.
context in which disease and malnutrition occur; that bio
logical answers cannot explain the huge differences in child
mortality around the world, nor the fact that a dispropor
tionate burden of disease, malnutrition, and death falls on
children in developing nations. They contend that these are
the symptoms of a single overriding disease—that of
poverty—and that the only lasting solution to the problem
is to alleviate the poverty in which these children live.
Both arguments of this historic debate are valid. There is
a biological cause for every death. A child drinks water from
a contaminated well and dies from severe dehydrating diar
rhea. The bacteria cause the dehydration; the dehydration
precipitates the death. But poverty plays a crucial role: a
tragic outcome might have been avoided had the commun
ity been able to provide clean water, or had the mother been
able to read the directions on an oral rehydration salts
packet. Poverty paves the way for both the disease and the
eventual death.
Bringing about the child survival revolution therefore re
quires systematic understanding of both aspects of child
mortality—social and biological—and their interaction in
the world. If child survival is to be improved at the rapid
rates we now know are possible, it is essential to take action
China
Latin America
& Caribbean
Developed0,2 0,2
Countries
Demographic Data for Development Project
on the comprehensive model now being developed by
leading authorities in the field, which takes account of both
factors. The following pages, which borrow from this
model, are devoted to both the immediate determinants of
child mortality and the socioeconomic context in which
children live. This includes the general categories of nutri
tion, infection, and maternal factors that put children at
risk, as well as health attitudes and resources that influence
child mortality through preventive and curative actions.
Each chapter in the first section describes a major impedi
ment to child survival and existing technologies that can
be used to remove it. The second section focuses on ma
jor socioeconomic resources and their importance. How
successful we are in overcoming these impediments and
developing these resources will determine how many of
tomorrow’s children live or die.
Perhaps the most important aspect of efforts to improve
childhood survival is what might be called “political and
social will”: the resolve to commit resources at national and
international levels and to develop broad-based health and
child-spacing programs that will both initiate and sustain
the dramatic increases in infant and child survival now
within reach.
7
00
World Child Mortality Rates
Map 1-A
Percent of children
dying before age 5
Less than 2
5-9
10-14
15-19
20 and over
Source: UNICEF (Data are included in Table 2 of Appendix 1.)
Demographic Data for Development Project
Major Impediments to Child Survival
and Strategies for their Removal
Diarrheal Disease
Vaccine-Preventable Diseases
Acute Respiratory Infection
Malaria
Malnutrition
High-Risk Fertility Behavior
a DIARRHEAL DISEASE
PROFILE
Figure 2-A
Diarrheal disease is the leading cause of infant and child
death in the world today. It is also one of the most frequent
causes of childhood illness and a major contributor to the
problem of childhood malnutrition. In developing regions
between one-fourth and one-third of deaths under age 5
have been attributed to this cause. In absolute terms, an
estimated 5 million children die from diarrhea every year.
At least 60 percent of these deaths result from acute dehy
dration, which we now know can be readily prevented.
Diarrhea Mortality as a Percent of
Mortality from All Causes:
Rural Bangladesh
Infant deaths: 143 deaths per 1,000
Child deaths, ages 1-4: 35 deaths per 1,000
Deaths from diarrhea
Agent
Diarrhea is only the common symptom of a large number
of intestinal diseases. The source of infection may be a
virus, a bacteria, or a parasite, or, often, a combination of
these. They all share the ability to alter intestinal function,
increasing fluid loss from the body and decreasing the
retention of nutrients. The severity of an episode varies
widely, depending on the type of diarrhea and the inten
sity of infection. Cholera has a well-earned reputation as
the most deadly diarrheal disease. It can kill in a matter of
hours and has claimed more lives in recorded history than
any single infectious disease, including the bubonic plague.
Yet cholera can also be a relatively mild disease, which il
lustrates the broad range in severity of diarrheal infections.
The impact of diarrhea is seen less in the severity of in
dividual cases than in the effects of the recurring mild in
fections that characterize childhood in many developing
countries.
Diarrhea kills primarily through dehydration. Although
life-threatening dehydration occurs in only 1 percent of all
episodes, it is responsible for 60 to 70 percent of all diar
rhea deaths. Without treatment, severe episodes literally
wring out body fluids from the victim faster than they can
be replaced. The first symptoms of dehydration appear after
fluid loss equivalent to 5 percent of body weight. When
fluid loss reaches 10 percent, shock often sets in, and the
cascade of events that follows can culminate in death
unless there is immediate intervention. Rehydration,
whether given orally or intravenously, is the only effective
therapy.
43%
Source: Chen, L.C., M. Rahman, A.M. Sarder, "Epidemiology and Causes of Death
Among Children in a Rural Area of Bangladesh," International Journal of
Epidemiology, 9(1): 25-33,1980.
Demographic Data for Development Project
highest rates of diarrhea occur during the hot and rainy
seasons. At high temperatures, bacteria multiply quickly in
food and water that have been left standing, and high rain
fall facilitates the spread of these organisms. The highest
prevalence often coincides with peaks in annual rainfall.
One study has found that during the rainy season in The
Gambia, the average child suffers from diarrhea more than
25 percent of the time.
Transmission Factors
Diarrheal disease is primarily transmitted from person to
person via soiled hands and via food and water that have
been contaminated by human waste. It is characteristically
endemic in areas where sanitation and hygienic habits are
poor. Seasonal cycles play an important role. In general, the
10
Host Factors
Diarrhea can strike at any age. But when diarrhea kills, its
victims are almost always children. It is estimated that 80
percent of child deaths from diarrhea occur before the age
of 2. The absolute risk of death from diarrhea declines
through the remainder of childhood, following the general
decline for overall mortality. But diarrhea then becomes a
more important cause of death in relation to other causes.
An analysis of child mortality in Bangladesh is shown in
figure 2-A The proportion of diarrheal deaths rises from 14
percent of all infant deaths to more than 40 percent of all
deaths among 1- through 4-year-olds.
The reasons for this increased vulnerability lie in the
unique transition children must undergo from their initial
state of nutritional and immunological dependence. During
the first 4 to 6 months of life, a fully breastfed infant receives
both a complete diet and disease protection from breast
milk. Exclusive breastfeeding also spares the infant early
exposure to contaminated food and water. The inevitable
introduction of supplemental foods, however, requires an
adjustment to diseases in the environment—an adjustment
not unlike that experienced by travelers in new surround
ings. As seen in figure 2-C, the highest rates of diarrhea
among children, which occur from the age of 6 months
through age 1, coincide with the weaning period.
Diarrhea and malnutrition are so closely related that they
may arguably be considered a single complex of diseases.
Diarrhea causes malnutrition. During a diarrheal episode
a child is likely to eat less, either because of loss of appetite
or intentional withholding of food, and absorbs less of the
food he does eat due to the effect of the diarrhea itself. At
the same time, malnutrition increases the risk from diar
rhea. Poorly fed children suffer longer and more severe
episodes. Even children who are of normal weight but have
selective vitamin A deficiency appear to be more vulnerable
to diarrheal attacks. The reciprocal effects of malnutrition
and diarrhea tend to multiply each other, together becom
ing a more powerful agent of death than either one alone.
An isolated case of mild diarrhea carries an impercep
tible risk. Yet children in developing countries face multiple
episodes of acute diarrhea every year. In some areas the
total is as high as 12. The cumulative nutritional deficit
from these relentless infections can interrupt normal
growth and development and place the child in a
precarious nutritional and health status.
GLOBAL IMPACT ON CHILD SURVIVAL
Current knowledge of the true global prevalence of diar
rheal disease suffers from a serious shortage of accurate
data. Nonetheless, available estimates provide a rough
outline of who is at greatest risk and where the problem
is most concentrated.
For the year 1984, the World Health Organization
estimated that there were over a billion episodes of acute
childhood diarrhea and almost 5 million child deaths from
this cause alone. More than 90 percent of these episodes
and almost all of the deaths occur to children in develop-
Figure 2-B
Estimated Annual Episodes of Childhood
Diarrhea and Average Number of Days of
Diarrheal Illness
Developing Regions and Selected U.S. Example
5
25 days
£
O
4.9
CJ
£
*
5
17 days
o
g
CD
CX
a>
3.3
5
Q.
13 days
CD
ex
v>
o>
2.2
■o
O
10 days
o
CD
X3
2.0
52
£■
6 days
E
a>
O)
Africa
Near East
Asia
Latin
America &
Caribbean
U.S.
Regions
Note:
An average episode of diarrhea is expected to last 5 days.
Source: For Developing Regions: World Health Organization, "Fourth Programme
Report for Control of Diarrheal Diseases 1983-1984," Program for Control
of Diarrheal Diseases, Geneva, Switzerland, 1985.
For U.S.: An average rate of 1.09 episodes/child under 5/year was
calculated from a community study in Michigan.
Monto, A.S., J.S. Koopman, "The Tecumseh Study. XI. Occurrence of
Acute Enteric Illness in the Community," American Journal of
Epidemiology, 112(3): 323-333,1980.
Demographic Data for Development Project
ing countries. The incidence of acute child diarrhea in the
developing world is 3 to 4 times greater than in the United
States and other developed countries.
The median diarrheal incidence figures for each region
are shown in figure 2-B, which also shows the average
number of days during a year that a child in the region
might suffer from diarrhea. These estimates, which are con
servative, suggest the great burden of illness on children
from this disease alone. The estimated annual attack rate
for Africa of almost 5 diarrheal episodes per child denotes
a formidable health risk. Assuming that each episode lasts
an average of 5 to 6 days, a child bom in Africa today will
spend 1 month of every year with diarrhea. Averages and
medians, however, always obscure the variation observed
for such a large and diverse area as Africa. Estimated inci
dence rates over the continent range from 2 to 10 episodes
annually. The greatest burden of illness falls on the youngest
children and the highest frequency is experienced during
n
one season of the year. The health risk of diarrhea to young
children during peak months in the poorest areas is thus
far more serious than the regional figures suggest. These
high rates serve as a real barometer for malnutrition, poor
sanitation, and marginal health conditions.
Figure 2-C
Estimated Median Diarrheal Episodes
Per Year by Age
THE ROAD TO HEALTH
The loss of life from diarrheal disease is staggering. Yet the
potential for saving the lives of children who die from this
disease is equally dramatic. Increasing attention has been
given to the problem of diarrhea since the development
of a simple technique to combat dehydration, which is the
principal cause of diarrheal death. The technique is oral
rehydration therapy, or ORT.
3.1
o
0)
Ll_
§
v>
Oral Rehydration Therapy (ORT)
•g<D
ORT is a three-tiered strategy that combines administra
tion of a simple solution of sugar and salts with continued
feeding through a diarrheal episode and referral when
appropriate.
ORT acts to replenish the water and electrolytes lost from
the body during a diarrheal episode. Diarrheal organisms
normally resist efforts by the body to balance these losses
by reducing intestinal absorption of fluid and nutrients.
Rehydration therapy is the only effective treatment for
dehydration, which in most cases is the ultimate cause of
death. For many years, intravenous rehydration was the
accepted treatment. It has now been found that a relatively
simple mixture of sugar and salts in a liquid solution can
be absorbed even during the course of severe illness. Ad
ministration of this mixture does not cure diarrhea, but
it can maintain or restore the body’s critical fluid balance
until the infection subsides. Continued feeding during the
illness lessens the risk of malnutrition that accompanies
frequent episodes. Because it is not specific to any one type
of diarrheal agent, ORT can be used against all cases of diar
rhea. Only in the severest cases of dehydration is in
travenous therapy still required.
ORT stands as a model of existing child survival
measures that are simple, effective, and low in cost. The
ingredients of oral rehydration solution are inexpensive
and widely available. The solution itself is simple to prepare
once the technique has been learned. And it can be made
either from a premixed packet of oral rehydration salts or
from common home ingredients (see figure 2-D). In prac
tical terms, this means that this simple yet powerful lifesav
ing technique can be practiced in the home and dissemi
nated in areas beyond the reach of a hospital or clinic,
where the majority of children in the developing world
live. Accordingly, ORT has been hailed as the most signifi
cant medical advance in child survival since the develop
ment of vaccines.
C/>
12
2.3
CD
0.5
0-5
3
2
6-11
Months
Years
Source: Snyder, J.D., M.H. Merson, "The Magnitude of the Global Problem of Acute
Diarrheal Disease: A Review of Active Surveillance Data," Bulletin of the World
Health Organization, 60(4): 605-613, Geneva, Switzerland, 1982
Demographic Data for Development Project
Expanding ORT Use
Despite intensive efforts to reach children at risk, ORT is
still not in widespread use. Since the technique’s introduc
tion in the 1970s, the global supply of oral rehydration salts
has increased dramatically. A number of developing coun
tries have begun to manufacture their own packets. But
these efforts have only begun to meet the world need.
Figure 2-F shows minimum estimates for the proportion
of children who have access to centers that dispense
packets and the proportion of estimated diarrheal episodes
actually treated, using packets or home solution. Minimum
estimates assume that countries not reporting have no
coverage. Typically, the geographic areas of greatest need
have the lowest rates of both access and use. Moreover,
available statistics are largely drawn from the small number
of countries that gather reliable statistics and, not coin
cidentally, offer better health services in general. Hence
the regional estimates provided here, low as they are, pro
bably do not understate the actual situation.
Making the lifesaving potential of ORT a reality means
placing this practice in the hands of those who need it
most. One of the greatest difficulties has been to get peo-
pie to recognize the need for treatment before it is too late.
Diarrhea is a common fact of life for many children.
Perhaps only 10 percent of cases become dehydrated, and
the symptoms of dehydration appear late in the course of
the disease. People in local communities, especially
mothers, need to learn how and when to give ORT when
their children contract acute diarrhea. Caregivers must be
carefully taught to use the correct proportions of salts in
water, because an over-diluted solution is less effective and
one that is too concentrated can be dangerous. The impor
tance of using the cleanest possible water must also be
stressed, to avoid exposing the child unnecessarily to fur
ther contaminants. But even if safe water is not readily
available, the benefits of fluid replacement in diarrhea far
outweigh the risk of using contaminated water to make up
oral rehydration solution. The crucial role that water plays
in disease transmission and health in general is discussed
further in chapter 12.
Finally, the spread of ORT can be gready accelerated by
carefully designed and implemented programs. This dif
ficult work is now being undertaken in efforts to make ORT
and diarrheal control an integral part of comprehensive
health services for children in the future.
The Importance of Continued Feeding
The solution of sugar and salt may prevent dehydration,
but does not address the problem of malnutrition that diar
rhea frequently precipitates. Continued feeding through a
diarrheal episode plus extra intake during the recovery
period are essential if a child is to maintain normal growth
and development. It is especially important for children
who are still breastfeeding.
Unfortunately, the common response to diarrhea is to
stop feeding altogether. It is a problem of conflicting percep
tions of this disease. Common sense tells many parents that
diarrhea works like a pipe. If you stop feeding things in at
the top, they will stop coming out at the bottom. This belief
is seemingly confirmed by the observation that diarrhea in
creases with feeding. Much of the food and liquid ingested
during diarrhea is indeed lost. But while gut function is
reduced, the body can still absorb over 50 percent of
nutrients during a diarrheal episode. Continued feeding in
conjunction with oral rehydration is thus best for die child.
Even if the diarrhea appears to get worse, feeding is a far
better alternative than fasting.
Young children in many parts of the world spend a
Figure 2-D
Oral Rehydration Solution
Sugar
Oral Rehydration Salt (ORS) Solution
3.5 grams Sodium chloride
20 grams Glucose
2.9 grams Trisodium citrate dihydrate’
1.5 grams Potassium chloride
1 liter of cleanest water
Salt
Home Solution
OR
1 level teaspoon Table salt
8 level teaspoons Sugar
pinch
Baking soda"
pinch
Potassium salt”
1 liter of cleanest water
■ Although the World Health Organization now recommends the use of trisodium citrate, oral rehydration packets substituting 2.5 grams of sodium bicarbonate remain safe and
highly effective.
" Although these increase the effectiveness of home solution, it is still effective without them. Readily available foods such as bananas, orange juice, and green coconut water
contain potassium, although relatively large quantities of these foods are needed to replace potassium lost from diarrhea.
Source: World Health Organization, Treatment and Prevention of Acute Diarrhea: Guidelines for Trainers of Health Workers, Geneva, Switzerland, 1985.
Demographic Data for Development Project
13
Figure 2-E
Estimated Access and Use of ORT In Developing Regions
Percent of Children with access to centers dispensing oral rehydration salt packets
8%
51%
Africa
Near East
Percent of diarrhea episodes treated with oral rehydration salt packets
3%
9%
Africa
Near East
Near East
12%
11%
Latin America
& Caribbean
Asia*
Percent of diarrhea episodes treated with ORT (packets or home solution)
5%
17%
Africa
Latin America
& Caribbean
Asia*
12%
12%
Latin America
& Caribbean
Asia*
‘Excluding China
Note: Regional averages represent minimum estimates for access and use. Countries not reporting are assumed to have no coverage.
Source: Adapted from data provided by the Program for the Control of Diarrheal Diseases/World Health Organization.
Data Available as of May 8,1986.
Demographic Data for Development Project
significant proportion of their lives with diarrhea. If food
or breastmilk were to be withheld for each episode, it
would be tantamount to requiring the hardest-hit children
to fast for a full month or more out of every year.
Diarrhea Prevention
Handwashing: The ultimate aim of diarrhea control pro
grams is to prevent the disease itself. Improvements in
sanitation and water supplies will certainly play an impor
tant and necessary role in the permanent reduction of diar
rheal illness. But the costs of building these systems and
maintaining them once they are built are prohibitive for
14
many areas at current levels of development. Meanwhile,
a number of simple preventive measures can have an im
mediate impact on the incidence of diarrheal disease. The
promotion of simple hygienic practices within the
household is a good example. Figure 2-F shows the impact
of a program in Guatemala to promote health awareness
and good hygiene among mothers in the country’s Pacific
lowlands. The incidence of diarrhea was lower and the
length of diarrheal episodes shorter among children of
mothers in the program than among children in similar liv
ing conditions whose mothers did not participate in the
program. The most dramatic results were achieved at the
peak diarrhea season among children under two. Diarrheal
incidence in this group declined by 36 percent, and the
time spent with diarrhea was reduced by more than half.
A simple bar of soap can be a powerful force for child
survival.
Breastfeeding: The practice of breastfeeding provides
a similarly dramatic level of protection from diarrhea. A
recent study of diarrhea in Costa Rica found that infants
who were exclusively bottlefed in the first 6 months of life
contracted diarrhea at 4 times the rate of partially breast
fed infants and almost 7 times the rate of exclusively breast
fed infants.
When mortality from diarrhea among exclusively breast
fed infants is compared with mortality among infants ex
periencing other feeding patterns, an even more striking
pattern emerges. During the first 6 months of life, exclusive
ly bottlefed infants are between 5 and 25 times more likely
to die from diarrhea than their exclusively breastfed counFigure 2-F
Impact of Hygiene Education on the Incidence
and Duration of Diarrheal Illness: Guatemala
Percent reduction in incidence of diarrhea
Percent reduction in number of days with diarrhea
55%
48%
36%
32%
f
24%
12%
■U
14%
14%
AGE 0-1
AGE 0-6
o
All Year Round
AGE 0-1
AGE 0-6
During Peak Season
Source: Feachem, R.G., "Interventions for the Control of Diarrheal Diseases among
Young Children: Promotion of Personal and Domestic Hygiene,"' Bulletin of the
World Health Organization, 62(3): 467-476, Geneva, Switzerland, 1984.
terparts, and between 2 and 13 times more likely to do so
than partially breastfed infants. The level of direct disease
protection from breastfeeding declines over the first year.
But breastfed children probably remain at a nutritional ad
vantage during the recovery period from a diarrheal epi
sode. The World Health Organization has estimated that
breastfeeding promotion programs could yield an 8 to 20
percent reduction in incidence of diarrheal illness and a
24 to 27 percent decrease in deaths from diarrhea. The role
of breastfeeding in child survival is discussed in greater
detail in the section on Malnutrition.
Immunization: Direct vaccination against diarrheal in
fection may soon provide an important weapon in the con
trol of diarrheal disease. In recent years, substantial
resources have been invested in research to develop a new
vaccine against rotavirus and an improved vaccine against
cholera. Rotavirus is a leading cause of severe, dehydrating
diarrhea among children around the world. While rotavirus-associated diarrhea may account for only 6 percent
of all diarrheal episodes among children under age 5, it
may be responsible for 20 percent of all diarrheal deaths
in that age group and as many as half of all episodes that
result in dehydration. Several candidates for a vaccine that
can be administered orally are currently being tested, with
some promising results. Once perfected, a rotavirus vac
cine might be given to children in conjunction with oral
polio vaccine, thus building on existing immunization pro
grams that have established broad coverage.
Cholera is rare by comparison to other major causes of
diarrhea, but its frightening severity and ability to create
explosive epidemics make it a logical target for continued
vaccine research. A number of oral vaccines are being
tested to improve on the duration and efficacy of the cur
rent injectable vaccine. Work also continues in develop
ing vaccines against other important agents of diarrhea,
including enterotoxogenic E. Coli, Shigella, and Giardia
lamblia.
A final prevention strategy against diarrhea takes advan
tage of the interaction of other disease antagonists with
diarrhea in affecting child survival. Diarrhea is a frequent
and often fatal complication of measles. The risk of a child’s
dying from measles combined with prolonged diarrhea is
4 times that of dying from measles alone. Immunization
programs aimed at measles should therefore have a tangible
impact on the death toll from diarrhea.as well. The World
Health Organization has estimated that if 60 percent of
1-year-olds were to receive measles vaccinations, the en
suing reduction in mortality from diarrhea among children
under age 5 would range from 9 to 18 percent. It is
estimated that up to one-fourth of diarrheal deaths could
be eliminated by 90 percent measles immunization
coverage.
Demographic Data for Development Project
15
VACCINE-PREVENTABLE DISEASES
PROFILE
Immunization is one of the most powerful weapons in the
arsenal of existing child survival technologies. The World
Health Organization’s Expanded Program on Immuniza
tion (EPI), with the support of USAID, UNICEF, and other
major groups, is conducting an ambitious effort to establish
universal immunization against six common childhood
diseases. They are measles, diphtheria, pertussis, tetanus,
poliomyelitis, and tuberculosis. Vaccines against these
diseases are for the most part safe, effective, and inexpen
sive. Widespread immunization in industrialized countries
has come close to eliminating these diseases altogether.
Real progress has also been made in efforts to reach
children in the developing world, as seen in figure 3-A. In
1985 vaccination is estimated to have prevented nearly a
million child deaths. Nevertheless, an estimated 3.5 million
infants and children continue to die annually from the
target diseases and their complications. An equal number
are left blind, crippled, or mentally retarded.
Measles is never a trivial disease. Among impoverished
children, high levels of malnutrition, crowded living con
ditions, and very young age at infection combine to make
it particularly devastating. Fatality rates from measles are
many times higher in developing regions, particularly in
Africa, than they are in industrialized countries. In the
United States fewer than .001 percent of measles infections
result in death. In developing countries today, the average
figure is close to 3 percent, with observed rates of nearly 4
percent in Bangladesh, 6 percent in Zaire, and more than
15 percent in Guinea-Bissau, according to a recent study.
Figure 3-A
Annual Child Deaths from Vaccine-Preventable
Diseases and Deaths Prevented by
Immunization in Developing Countries
Child Deaths
AGENT
Measles: Measles is a viral infection that causes more child
deaths than all of the other target diseases combined.
According to the most recent data available, more than 2
million children died from measles and the diarrhea, pneu
monia, and malnutrition that measles precipitates. The
disease is characterized by high fever, cough, runny nose,
and a blotchy rash that appears over the body 3 to 7 days
after the onset of symptoms. The virus is highly contagious
and easily spread from person to person. Without immuni
zation, virtually all children will contract measles.
The power of this disease to cause death stems in large
part from its devastating effects on the nutritional and im
mune status of its victims. The fever can quickly deplete the
body’s reserves of both protein and vitamin A, even in
children who are well-nourished. The danger is far greater
for children already in a precarious nutritional state.
Because protein and vitamin A play a role in maintaining
the body’s defenses against disease, a child suffering from
measles is immunologically compromised, which renders
him vulnerable to a cascade of complicating infections.
Measles rarely kills alone. It is almost always aided by at
least one other disease, most commonly diarrhea or pneu
monia. Children who recover are often left with a serious
nutritional debt. Measles has frequently been cited as the
major precipitating event in severe protein-calorie malnu
trition, leaving as many as one-fourth of infected children
with a formidable 10 percent weight loss.
16
Deaths Prevented
371
Total Deaths - 3,548,000
Total Deaths
Prevented
731,000
■o
s
s
2,110
jC
a>
<n
g
O
j*-
I
>
oZ
132
o
q>
839
228
599
JC.
Measles
Neonatal
Tetanus
Pertussis
Target Diseases
Source: WHO Expanded Programme on Immunization.
Data available as of July, 1986.
Demographic Data for Development Project
Tetanus: Tetanus is a highly lethal infection caused by
the toxin of the tetanus bacillus. It is responsible for close
to one million deaths each year; most of those who suc
cumb are newborn infants. This organism exists harmlessly
in the gut of many animals and humans. It is only when the
bacillus enters through the skin or an open wound that it
becomes fatal. The usual mode of transmission is through
exposure to the soil, where excreted tetanus spores can
remain intact for years. People of all ages can be suscept
ible to infection. It is of particular concern to those who live
in rural areas and in the unsanitary conditions under which
the tetanus bacillus thrives. Vaccination with tetanus toxoid
confers immunity for up to 10 years and can provide
important protection for older children and adults in highrisk areas.
Neonatal Tetanus: Tetanus that occurs during the first
month of life, or neonatal tetanus, accounts for the greatest
number of deaths from this disease. It results primarily
from unsanitary practices surrounding birth. The newly cut
umbilical stump provides an easy portal of entry for the
tetanus bacillus, which can be introduced by contaminated
cutting instruments or by the traditional dressings some
times placed on the umbilical stump. The first sign of
neonatal tetanus is inability to feed. In a matter of days, the
disease proceeds to general muscular stiffness with spasms
and convulsions. Death follows rapidly. Most deaths occur
between 4 and 14 days of birth, several days after the first
symptoms appear. Without treatment neonatal tetanus is
almost uniformly fatal; the assumed case fatality rate is 85
percent. Even when treatment is available, mortality is high
because babies are rarely brought to the hospital before
severe symptoms have set in.
Until recently, the global significance of neonatal tetanus
had gone largely undetected. The death of a child during
its first few weeks of life may be hidden from view for
cultural reasons. In many traditional societies, a child must
survive for a certain period of time after birth before it is
acknowledged as a “life.” Naming ceremonies and other
rituals marking the arrival of a new life are purposely
delayed by those accustomed to high rates of infant mor
tality. The fatalistic attitudes that prevent parents from
seeking help also make them unlikely to report the death
of a newborn infant. As a result, the problem of neonatal
tetanus has been endowed with what has been called a
“peculiar quietness,” going largely unrecognized as a ma
jor cause of infant death.
The true magnitude of neonatal tetanus mortality is
uncertain. Current estimates hold that close to 1 million
infants die from this cause every year. In some areas it
accounts for more than half of all deaths in the first month
of life and 1 in 10 deaths during the first year.
Prevention is the only viable strategy against this disease.
Unlike other diseases discussed in this section, tetanus is
Figure 3-B
Neonatal Mortality With and Without
Health Intervention
Cause of Death
I Neonatal Tetanus
All Other Causes
61
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o
o
o
CD
Q.
£
s
s
38
CD
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24
=>
<0
18
o
Q
1
6
Mothers
Immunized
Against Tetanus
During Pregnancy:
No Trained
Birth Attendant
Delivery by a
Trained Birth
Attendant:
No Immunization
No
Health
Intervention
Source: Stansfield, J.P., A. Galazka, "Neonatal Tetanus in the World Today," Bulletin of
the World Health Organization, 62(4): 647-669, Geneva, Switzerland, 1984,
Demographic Data for Development Project
not contagious. It can be prevented by immunization and
improved sanitary conditions, especially those surrounding
maternity care. Immunization strategies against neonatal
tetanus hold out the greatest hope for the immediate future.
The timing of this disease requires an unorthodox solution.
When a pregnant woman is immunized, her fetus also
receives immunity. Following birth, the child enjoys this
passive immunity for up to 5 months, safely past the period
of highest risk. Basic improvements in maternity care also
have important implications for child survival. Figure 3-B
shows the influence of trained birth attendants and
immunization of pregnant women on neonatal mortality
from tetanus and from all causes combined. As might be
expected, delivery by trained birth attendants reduced
neonatal mortality from all causes to a greater extent than
immunization against tetanus. Immunization against neo
natal tetanus, however, provided virtually complete protec
tion to infants of immunized mothers. Compared with
those receiving no special care, newboms in both programs
enjoyed a significant reduction of mortality during the first
17
month of life, 72 percent and 54 percent respectively,
which underscores the importance of pre- and postnatal
health care.
Pertussis (Whooping Cough): Pertussis, an acute
bacterial infection of the respiratory tract, claims the lives
of nearly 600,000 children each year. Without immuniza
tion, the toll in developing countries might be closer to
750,000 child deaths annually. Characterized by a violent
cough and whooping sound with inhaled breath, pertussis
is a prolonged, exhausting illness. The severest symptoms
usually occur over a period of 2 to 4 weeks. A residual
cough may last for months. It is highly contagious. On
average, 80 percent of children in an unimmunized
population will contract this disease. An estimated 1.5 to
2 percent of infected children die from pertussis and its
consequences, especially from pneumonia. As with
measles, children who recover are often left with a nutri
tional debt that weakens their resistance to the effects of
other illness. More than half of the children in one African
study suffered a critical 5 percent weight loss. It took from
1 to 3 months for many of these children to regain their
previous weight and resume normal growth. The burden
on health from this preventable disease may thus be far
greater than can be measured directly.
Polio: Polio is more of a crippier than a killer. It is a viral
disease spread indirectly from person to person via con
taminated food and water. An estimated 272,000 children
contracted paralytic polio in 1985 and perhaps one in ten
of these died as a result of the infection. Spearheaded by the
Pan American Health Organization’s drive to eradicate
polio from the Americas before the next decade, the world
is gaining the edge on this dread disease. The estimated
number of cases prevented by polio immunization in
developing countries in 1985 was almost half the reported
incidence of childhood polio in that year.
Polio was once thought to be a relatively rare disease that
occurred more frequently in developed than developing
countries. The disease seemed rare because most polio in
fections are silent. Only one of every 200 children infected
goes on to develop paralysis. Amid poor health conditions,
frequent exposure to polio virus begins at birth. Recent
lameness surveys in developing countries reveal previously
unsuspected high levels of crippling polio, comparable to
those of the worst epidemics in industrialized countries
before the development of vaccines. Some 3 to 10 children
per 1,000 are affected in endemic areas.
Diphtheria: Since immunization against diphtheria
began, this once-dreaded disease has been all but relegated
to memory in temperate countries. In the United States, for
example, the number of reported cases averaged four per
year during the early 1980s, occurring mostly in unim
munized adults. Little is known about the scope of diph
theria in the developing world. Perhaps 5,000 children die
18
Figure 3-C
Measles Case Fatality Rates by Age
Percent of Infected Children Who Die From
Measles: West Africa
8%
6%
o>
Q
s
<D
0%
1%
0
2
3
5
Age in Years
Source: Foster, S.O., "Immunizable and Respiratory Diseases and Child Mortality,"
Child Survival: Strategies for Research Population and Development Review,
Supplement to Vol. 10, L.C. Chen, H. Mosely (ed.) (New York: The Population
Council, 1984).
Demographic Data for Development Project
each year from this cause. While this death toll is low com
pared with that of a disease like measles, immunization re
mains a priority. The infection is severe, killing 10 to 15
percent of its victims. Many children in endemic areas
develop an early natural immunity as a result of constant
subde exposure to the bacteria through the skin. Ironically,
as health and sanitary conditions improve, such exposure
decreases, depriving children of this natural immunity and
making them susceptible to the severe respiratory form of
diphtheria later in life. Immunization thus becomes a
critical factor in preventing the rise of both morbidity and
mortality from diphtheria.
Tuberculosis (TB): Once the leading cause of death in
Europe, tuberculosis now appears to be declining through
out the world. Throughout its history, the disease has been
associated with the poverty and crowded living conditions
that favor its spread. It is now rare in developed countries,
but remains common in developing regions, where it con
tinues to be a major cause of illness and death. Although
the true scope of this disease among children is unknown,
it is estimated that 30,000 children die from tuberculosis
each year.
Tuberculosis is a chronic disease that usually starts in the
lungs and may spread to other organs. Most child deaths
result from a severe form of the disease known as TB
meningitis, which develops when infection spreads to the
J
J
layers surrounding the brain. Like polio, most tuberculosis
infections are silent. Between 1 and 2 percent of those
harboring the bacillus develop outward symptoms each
year. But unlike polio, tuberculosis is not self-limiting.
Without treatment, the bacillus may persist in the lungs of
the victim indefinitely, ready to cause infection later in life.
An infected infant has a 10 percent chance of developing
disease in later childhood or as an adult.
Host Factors
]
It is striking that the same childhood diseases can be so in
nocuous in one context and so devastating in another.
Their tremendous impact on child survival in developing
countries stems from four principal factors: low levels of
immunization (discussed in the next section), young age
at infection, the presence of malnutrition and other com
plicating diseases, and lack of available health care.
Age at infection can have a strong influence on the sever
ity of the disease. Childhood diseases tend to strike at much
earlier ages in developing countries than in industrialized
countries. In poor, densely populated areas, as many as half
of children will have suffered measles by their first birthday;
virtually all have been infected by age 3. Contributing fac-
tors include crowded living conditions that give children
early exposure to the outside world. A child who lives in
one room with a number of older siblings or who rides on
his mother’s back to a crowded marketplace is likely to be
exposed to most common childhood diseases at a very
early age. In developed countries, by contrast, most
children first encounter this intensity of exposure when
they enter school at age 4 or 5. The pattern of declining
fatality rates from measles with increasing age (figure 3-C)
shows that an infant with measles is 8 times more likely to
die than a 5-year-old with the same infection. Similarly, the
risk of death among infants with pertussis is 3 times that of
children 1 or older.
The combination of malnutrition and concurrent illness
is a recurring theme in discussions of the major determi
nants of child mortality. The case of measles provides a
classic example of the interplay between these factors.
Severely malnourished children have been shown to suffer
twice the measles mortality of children on adequate diets.
Under famine conditions, when the prevalence of mal
nutrition soars, as many as half of children who contract
measles die from it. Most measles deaths follow com
plicating infections, usually diarrhea and pneumonia. A
Figure 3-D
Immunization Coverage by Region
Percent of 1 -Year-Olds Fully Immunized
Diphtheria, Pertussis,
Tetanus (3 doses)
U Tuberculosis
Polio (3 doses)
Measles
92
87
80
66
62 SSL
56
54
37
....
28 27
44
38
59
53
37 ft
31
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I d BP
Africa
Near East
Asia’
Latin America &
Caribbean
Developed Countries
’Excluding China
Note:
Countries not reporting are excluded from regional averages.
Source: WHO Expanded Programme on Immunization.
Data available as of July 1986.
Demographic Data for Development Project
19
I
Figure 3E
Immunization Coverage and Incidence of Immunizable Diseases
for Selecting Developing Countries, 1974-1984
Percent Coverage
_ Incidence per 100,000 population or 1,000 live births in cases of neonatal tetanus
Diptheria in Sri Lanka
Polio in Colombia
Neonatal Tetanus in Sri Lanka
2.5
100 2.5
2
80
2
80
2
80
Ya-/ :
1.5
60 1.5
60
1
40
40
0.5
0.5
20 0.5
20
0
0
0
0
0
1.5
1
\__________ :
74 7 5 76 77 78 79 80 81 82 8 3 84
74 75 76 77 78 79 80 81 82 83 84
74 75 76 77 78 79 80 81 82 83 84
YEAR
YEAR
YEAR
Measles in Peru
Pertussis in Saudi Arabia
Polio in Brazil
150
120
90
60
30
0
100 150
100100 5 5
I
80 120
80
4
I
80
60
-VP:::
40
20
s
__ ____ ____ ____ _________ „„ „„ n.
74 75 76 77 78 79 80 81 82 8 3 84
74 75 76 77 78 79 80 81 82 83 84
YEAR
YEAR
Source: World Health Organizalion/Expanded Program on Immunization.
Bangladesh study found measles followed by prolonged
diarrhea to be four times more likely to be fatal than
measles alone. The synergistic effect of the interaction of
two diseases thus far outweighs the total of their individual
effects.
Lack of health care is another contributor to high fatality
rates from childhood diseases. Some of these diseases can
be cured medically. Pertussis and diphtheria respond to
antibiotics; tuberculosis can be halted by a complex drug
regimen; and it is possible to save some children from the
grip of tetanus by the use of muscle relaxants and anti
toxins. But few in the developing world have access to such
advanced medical services, and for other diseases, such as
measles or polio, there is no known cure. Immunization is
the only alternative. In any case, the continuing lack of
available health care is one of the strongest arguments for
immunization.
20
100
o
qh Qi
74 -,75c 76 -n
77 -io
78 in
79 80
81 82 83 84
YEAR
Demographic Data for Development Project
THE ROAD TO HEALTH
We hold the means to prevent millions of child deaths in
our hands. The virtual elimination of the six target diseases
in industrialized regions puts this goal within reach of the
developing world. It is no longer a question of the ability
to control these diseases; it is a question of the will to take
the necessary steps.
Immunization Coverage
The latest available immunization rates for the major
regions of the world are shown in figure 3-D. They reflect
the progress that has been made and the distance remain
ing to the goal of universal immunization. Africa lags well
behind other regions in terms of overall coverage. Fewer
than 40 percent of infants receive full immunization against
any of the six target diseases before their first birthday.
Asian countries (excluding China), provide higher levels
of coverage of all diseases but measles; immunization
against this disease is lower in Asia than in any other region.
India, which has more children than any country in the
world, has only recently initiated a measles immunization
drive. Even when India is excluded from the regional
average, measles immunization coverage averages less than
20 percent. China, by contrast, is reported to have reached
more than half of all infants with each vaccine; nearly 83
percent are said to be protected against measles. The
greatest overall success rates in the developing world have
been achieved by Latin America and the Caribbean, where
between one-half and two-thirds of infants are reportedly
immunized annually against each of the six target diseases.
The World Health Organization’s Expanded Program on
Immunization (EPI) faces significant challenges. Because
the targeted diseases strike in infancy in developing regions,
effective immunization must occur before a child’s first
birthday. Vaccinations must not be given too early,
however, because they can be neutralized by the passive
immunity inherited from the mother. This leaves a rela
tively brief period of time during which it is crucial to reach
the child. Additional problems include the need to refriger
ate vaccines until they can be administered. Breaks in the
required “cold chain” have a cumulative effect on vaccine
potency, especially on the potency of “live” vaccines such
as those against polio and measles. If there are too many
breaks, the vaccine becomes useless before it can reach the
child. Public awareness may be the most important factor
in the success or failure of these programs. Adequate sup
plies, facilities, and personnel mean little if local com
munities are not informed of the availability of services or
motivated to use them. Dropouts often plague immuniza
tion efforts, as when parents who bring in their children for
the first inoculation of DPT or oral polio vaccine fail to
return for the second or third shot.
Vigorous communication activities that get the message
across to the critical audience can be of enormous benefit.
Effective communication systems serve three purposes:
they educate people about the importance of immuniza
tion to children’s health, overcome misconceptions that
discourage its widespread use, and explain where and
when immunization services are available.
Nationally publicized “immunization days,” during which
thousands—or even millions—of children are immunized
have been staged in some countries. These widely publi
cized efforts tend to reach children who might otherwise
have gone unprotected. If these campaigns have a
drawback, it is that they may sidetrack efforts to establish
thorough systems of routine immunization to protect
future generations. However successful they may be, single
campaigns do not eliminate the ongoing need for im
munization. The absolute size of this need is vast. In 1985
there were 103 million infants living in developing coun
tries, only one quarter to one half of whom received im
munizations against any of the 6 EPI target diseases. By the
year 2000, the number of surviving infants is projected to
grow to over 115 million annually. That means that every
year there will be almost one million more children to im
munize than there were the year before. Overall, a projected
1.8 billion infants will require immunization between 1985
and the year 2000. The goal of universal coverage can be
achieved and sustained, but coordinated and systematic ef
forts will be required to support the necessary special
initiatives.
Despite logistical difficulties of immense proportions,
there is widespread agreement that the goal of universal im
munization of children can be achieved before the end of
the century. WHO’s Expanded Program on Immunization
is receiving broad-ranging support and other international
organizations and world leaders have added their voices to
the call for universal immunization of children by 1990.
The Pan American Health Organization is spearheading a
drive to eradicate polio from the Americas by that year. The
worldwide demand for vaccines has tripled during the past
year, and many countries have staged massive national im
munization drives. The series of graphs in figure 3-E shows
the impact of immunization on the incidence of disease in
selected countries. Increasing immunization rates of
children under age 1 accompany a general decline in the
pattern of the specific target disease. The benefits of these
programs are expected to accrue rapidly. As levels of im
munization rise, the number of susceptible children in a
given area declines. Above a certain level, different for each
disease, transmission can be brought to a virtual halt, which
means that even children who have not been vaccinated
are sheltered from infections. The analogy has been made
of a stone hitting sand. When a child contracts a disease
and there is no one for him to pass it on to, the epidemic
stops before it begins.
21
IV. ACUTE RESPIRATORY INFECTION
A host of other infectious and parasitic diseases can strike
children. Some are universal diseases of childhood, others are
limited to developing countries. Some are determined by
climatic conditions, others by crowding and poor hygienic prac
tices. Their impact on child survival is magnified by malnutri
tion and little or no access to health care. Thefollowing section
focuses on the two most important infectious and parasitic
diseases that affect children: acute respiratory infection and
malaria.
PROFILE
With the exception of diarrhea, no single group of diseases
claims as many child lives as acute respiratory infections.
These infections are estimated to account for 20 to 25 per
cent of all child deaths in the developing world. In absolute
terms, up to 4 million children die from these infections
every year. In some areas, acute respiratory infection
outranks diarrheal disease as the leading cause of death
under age 5.
Agent
As with diarrhea, acute respiratory infections are caused by
a wide variety of disease agents. More than 300 types of
bacterial and viral sources have been identified, including
four of the vaccine-preventable target diseases (measles,
diphtheria, pertussis, and tuberculosis). These infections
range in severity from the common cold to bacterial
pneumonia.
Acute respiratory infections are traditionally divided into
two main categories: those of the upper respiratory tract
and those of the lower respiratory tract. The latter group,
by far the most important cause of deaths from these
diseases, is the focus of current health strategies. Bacterial
infection of the lower respiratory tract is particularly
dangerous; bacterial pneumonia dominates all forms of
these infections as a killer of children. Control of lower
respiratory infection is problematic, however, because it is
relatively rare by comparison to upper respiratory infection
and difficult to diagnose. It often develops from seeming
ly harmless upper respiratory infections, which have a
notorious tendency to invite secondary, complicating
illness.
Transmission Factors
Acute respiratory infections are primarily spread from per
son to person through the air. Their principal transmission
factors are high population density, crowded living condi
tions, and seasonal changes that favor the spread of disease.
22
The evolutionary theory of disease holds that acute respi
ratory infections came into being when humans began to
form permanent settlements with large numbers of inhab
itants. Measles, for example, requires a minimum popula
tion of 100,000 in order to remain endemic in an area.
Because high population density facilitates the transmis
sion of person-to-person diseases, isolated rural com
munities that generally lack health benefits, may, in the
case of acute respiratory infections, enjoy a health advan
tage over populous urban areas.
Within households, crowded living conditions also favor
the spread of respiratory infection. In the often-primitive
traditional dwellings and poor housing where most of the
world’s children grow up, it is common for the entire family
to sleep in the same room. Infants and young children are
thus exposed at early ages to diseases brought into the
home by parents and older siblings. Moreover, intimate liv
ing conditions can increase the intensity of disease
transmission. Both very early age at infection and increased
intensity of infection have been implicated in the extraor
dinarily high fatality rates attributable to acute respiratory
infections in developing countries.
Seasonal epidemics of these infections are a universal
affliction of our species, regardless of economic classifica
tion or political boundaries. Every climate has its season of
increased disease transmission. The cold weather “flu
season” in temperate climates corresponds to the humid
rainy seasons of the tropics.
Host Factors
The principal risk factors for child mortality from acute
respiratory infection are young age, low birth weight, and
poor nutritional status. Death rates are highest during the
first year of life. These infections, particularly pneumonia,
are often the leading cause of infant death in impoverished
areas. As with other diseases, the deadly power of a severe
infection is multiplied by the convergence of such factors
as weaning, the gradual loss of passive immunity, and
increasing exposure to disease that mark the passage of
children through the critical first year of life.
An important contributor to high infant mortality from
acute respiratory infections is low birth weight. Death rates
from all causes are significandy higher for infants weighing
less than 2,500 grams (5.5 pounds) at birth, who appear to
be especially vulnerable to respiratory illness. Pneumonia
heads the list of infectious causes of death. The link bet
ween low birth weight and early death is reflected in the
elevated infant mortality rates of developing regions, where
about one child in six is bom underweight.
GLOBAL IMPACT ON CHILD SURVIVAL
Figure 4-A
Acute Respiratory Infection Mortality
by Nutritional Status
Philippine Hospital Cases
7.7%
O)
Q
2.3%
0.6%
Normal
Malnourished
Mild
Severe
Acute respiratory infections are by far the most common
illnesses suffered by children, no matter where they live.
The average child under the age of 5 experiences between
4 and 8 infections a year. These infections reportedly cause
from 20 to 60 percent of visits to health services and com
prise 10 to 50 percent of hospital admissions. The in
cidence of childhood respiratory infection is roughly the
same in both developed and developing regions. This is in
sharp contrast to the incidence of diarrheal disease, which
is 3 to 4 times higher in developing countries.
Although there is little regional variation in overall in
cidence rates of acute respiratory infection, death rates are
dramatically higher in developing countries. A major factor
in this difference is in their higher incidence of the most
severe infections, particularly the dangerous lower respi
ratory infections. Rates for these infections in India and
Papua New Guinea are 3 to 4 times higher than U.S. rates,
and in the rural highlands of Guatemala, half of 3-year-olds
have at some time suffered pneumonia. The differences are
not only in terms of incidence. Case fatality rates for
pneumonia, which are .4 percent in the United States, range
from 5 to 20 percent in developing areas. When incidence
and case fatality considerations are combined, death rates
from acute respiratory infections are in some cases hun
dreds of times greater for children in developing countries.
Nutritional Status
Source: Tupasi, T.E., "Nutrition and Acute Respiratory Infection," Acute Respiratory
Infections in Childhood. Proceedings of an International Workshop, Sydney,
Australia (1984), R. Douglas, E. Kerby-Eaton (ed .) (Adelaide, Australia University of Adelaide, 1985).
Demographic Data for Development Project
The impact of acute respiratory infections is intensified
by malnutrition. In Costa Rica, children with severe pro
tein calorie malnutrition were found to be 19 times more
likely than normal children to develop pneumonia. In the
Philippines, as shown in figure 4-A, mortality among
children hospitalized with acute respiratory infection was
far higher for malnourished children than for children of
normal nutritional status.
Vitamin A deficiency, long recognized as the leading
cause of blindness in childhood, may also be an important
risk factor for respiratory infections. Lack of vitamin A is
thought to cause physical changes in the internal linings of
the lungs and digestive tract which favor bacterial infection.
Figure 4-B shows the findings of recent research on this
subject in Indonesia. Children with ocular symptoms of
vitamin A deficiency experienced twice the rate of
respiratory infection and four times the death rate of
children without these symptoms. The role of vitamin A in
child survival is examined further in the section on
Malnutrition.
THE ROAD TO HEALTH
Acute respiratory infections are now being given increas
ing attention by the international health community. With
the exception of those for which vaccines exist, these in
fections have often been overshadowed in the past by other
health concerns. This neglect may have stemmed from the
lack of a central strategy like oral rehydration therapy,
which has galvanized the fight against diarrheal disease. But
growing awareness of the magnitude of the problem of
acute respiratory infections and the growing number of
possibilities for their prevention and cure have stimulated
new interest. Moreover, it has become increasingly
apparent that the child survival revolution will not take
place without successfully confronting this major cause of
childhood mortality in the developing world.
Existing control technologies include immunization,
drug therapy, and a variety of measures to reduce the risk
from this disease group. Four of the most important respi
ratory infections — measles, diphtheria, pertussis, and
tuberculosis — have been targeted by the Expanded Pro
gram on Immunization. Research on new vaccine treat
ments is ongoing. The development of vaccines against
lower respiratory infections could provide a much-needed
catalyst for the control effort. Drug therapy provides a po
tent defense against respiratory infections in developed set-
23
Figure 4-B
Incidence of Acute Respiratory Infection Among Children
With and Without Ocular Symptoms of Vitamin A Deficiency*—Indonesia
With ocular symptoms
Without ocular symptoms
19.1
o
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CL
s
5
o
o
o
7.9
8.6
Q.
o
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</>
sw
2.6
Q
2
0-1
Age in Years
With ocular symptoms = children with night blindness or Bitot's spots at both start and end ot 3-month observation interval.
Without ocular symptoms = children with normal eyes at both start and end of interval.
Source: Sommer, A., J. Katz, I. Tarwofjo, "Increased Risk of Respiratory Disease and Diarrhea in Children with Pre-existing Mild Vitamin A Deficiency,"
American Journal of Clinical Nutrition 40,1984.
*
tings, but its use poses special difficulties in many develop
ing countries. Requirements for facilities, trained health
personnel, diagnostic capabilities, and continuous drug
supplies can be daunting. Most developing countries lack
the resources to provide this type of curative service to
more than a small segment of the population in need.
Additional measures that would aid efforts to control
acute respiratory infections include promoting good nutri
tion, improving housing conditions, and expanding health
facilities and health education. Teaching mothers and other
caregivers to recognize the early stages of lower respiratory
24
infection in areas where medical help is available could be
lifesaving for many children.
Reductions in respiratory diseases accounted for a signifi
cant proportion of the mortality decline in developed
countries over the last century. Much of this decline took
place before the introduction of modem medical cures. Im
provements in nutrition, sanitation, and housing condi
tions are generally given most of the credit. Similar socio
economic improvements aided by current medical knowl
edge hold the promise of still more rapid declines for
developing countries.
MALARIA
l
PROFILE
Malaria has been called “the king of diseases.” The hun
dreds of pathogens that cause diarrhea and respiratory in
fections may claim more lives, but no single agent of
disease can match the power of the malaria parasite to in
flict suffering and death. More than half of the world’s
population continues to live at some risk of malaria. On
ly a small fraction of the estimated 200 to 400 million new
cases occurring each year are ever reported.
Malaria plays a critical role in child survival: pregnant
women, infants, and young children are at greatest risk of
severe infection. This group is also at disproportionate risk
of death. In areas where transmission is heavy, malaria may
account for as many as 10 percent of all deaths before age
5. The disease also contributes to high rates of spontaneous
abortion, low birth weight, and malnutrition in affected
areas. Despite determined efforts to eradicate or control
malaria, it remains a powerful enemy of health and survival
in much of the developing world today.
Figure 5-A
The Life Cycle of Malaria
6 Gametes join and
malaria completes
life cycle within
the mosquito
/
x-'
yMalaria parasite
enters the body
with the bite of an
infected mosquito
5 Another mosquito
bites, draws in
malaria gameto
cytes, and
becomes infected
2 Malaria first infects
the liver
4 Parasite begins
reproductive phase
Agent
The parasite responsible for malaria, a plasmodium, re
quires the interaction of human and mosquito to complete
its life cycle, as shown in figure 5-A. Plasmodia, which
reproduce inside the mosquito, are passed into the human
blood stream when the mosquito bites. Once inside the
human, the plasmodium passes through several stages, in
fecting first the liver and then the red blood cells, causing
the classic pattern of chills, fever, and sweating, sometimes
with delirium, that can result in death. Some forms of the
malarial parasite lodge in the liver, where they retain the
potential to cause recurrences of the disease throughout the
lifetime of the victim. When an infected human is bitten by
a mosquito, the seeds, or gametocytes, of the plasmodium
in the blood pass to the insect, and the cycle begins anew.
Transmission Factors
Depending on its prevalence in an area, malarial disease is
considered to be either epidemic or endemic. Epidemic
malaria occurs sporadically in areas where the disease is
unstable. Malaria is said to be endemic to an area if the
parasite is always present in the population at some level.
The extent to which conditions for transmission are met
determines the extent to which malaria becomes stable, or
endemic.
The level of malaria in a community is determined by a
combination of environmental factors and the interactive
behavior of human and mosquito. As a primary condition,
the parasite requires the presence of both humans and
3 Malaria next infects
the red blood cells
Demographic Data for Development Project
malaria-carrying Anopheles mosquitoes in sufficient
numbers to ensure continuous transmission. The mosquito
population and consequent risk of disease fluctuate with
seasonal patterns of temperature, humidity, and the
availability of breeding sites. Warm, humid climates favor
the reproduction of both the mosquito host and the para
site itself. Favorable climatic conditions also extend the
mosquito’s life span, thereby increasing the spread of the
disease. Thus, although malaria has essentially been erad
icated in Europe and the southern United States, it remains
deeply entrenched in most tropical and subtropical cli
mates where mosquitoes can live and breed year-round.
The insect’s behavioral patterns play an important role
in the transmission and control of malaria. There are many
different species of Anopheles mosquito, each with vary
ing patterns of breeding and feeding. Some breed in shaded
areas, some in bright sunlit water; some rest on the inside
25
ro
cn
-
0
SINGAPORE.
AREAS IN WHICH MALARIA HAS DISAPPEARED, I3EEN ERADICATED. OR NEVER EXISTED
AREAS WITH LIMITED RISK
AREAS WHERE MALARIA TRANSMISSION OCCURS
Reprinted with the permission of the World Health Organization.
walls of houses before biting, others feed and rest outside
the confines of human dwellings. Certain species feed pref
erentially on humans, others live off domesticated or wild
animals. The risk of malaria can therefore vary gready even
within the same climate.
Malaria transmission is often increased inadvertendy by
human activity. Irrigation and farming practices can pro
vide new breeding sites for mosquitoes. Human migration
can introduce the parasite into previously unaffected
populations or cause a resurgence of malaria in areas where
control measures have lapsed. In South America’s Amazon
basin, for example, rapid population influx and abrupt
alterations to the environment have created the conditions
for endemic malaria in an area where the disease had been
virtually unknown.
Host Factors
There is no complete natural immunity to malaria. Follow
ing repeated infections, it is possible for adults to develop
limited resistance to the severest forms of malarial illness.
Even then, malaria remains a serious disease. By some
accounts, it causes more loss of healthy life in endemic
areas than any other single disease.
The extent to which malaria is common or endemic to
an area will determine its effect on child survival. In areas
where transmission of the parasite is sporadic, malaria is
rare and a sudden epidemic can affect all age groups equal
ly. In endemic areas where transmission is continuous and
malaria is entrenched, many adults develop a partial
immunity to the parasite. Increasing levels of transmission
Figure 5-B
Impact of Malaria Control on Infant Health and Survival:
Comparison of Treated and Untreated Villages in Kenya, 1970-73
Treated Areas
Cumulative Infant Deaths in
Treated and Untreated Areas
Malaria Infection During Infancy
in Treated and Untreated Areas
100
150
75
I
100
o
50
o>
a>
c
a
)
w
a>
sa>
Q_
E
z
50
25
I
I
I
i
►
0
0
0123456789
Age in Months
10
11
Age in Months
Source: Payne, D.. B. Grab, R.E. Fontaine, J.H.G. Hempel, "Impact of Control Measures on Malaria Transmission and General Mortality," Bulletin of the World Health Organization, 54: 369-377,
Geneva, Switzerland, 1976.
Demographic Data for Development Project
27
■
lower the average age at first infection, thereby shifting the
heaviest burden of illness and death towards the youngest
age group. At the highest levels, 100 percent of children suf
fer from malaria before age 5. Most of these children will
experience their first infection in infancy.
Pregnant women are at heightened risk from malaria
infection. For reasons that are not clearly understood,
women lose whatever partial immunity they may have
against the parasite during early pregnancy. Immunologi
cally, they revert to the status of young children. This
phenomenon is most pronounced during a first pregnancy
and diminishes with each successive pregnancy. Upon the
birth of the child or shortly thereafter, the women regain
their ability to resist the disease. But severe malarial infec
tions during the exposed period can cause stillbirth, fetal
growth retardation, or premature delivery. Low birth
weight among surviving infants greatly increases their risk
of death from all causes through the first year of life (see
section on Malnutrition).
The potential health gains from controlling this single
disease are enormous. The direct impact of malaria on
child survival is still a debated issue. Malaria accounts for
10 percent of all child deaths in highly endemic areas, but
this figure does not include the silent contribution malaria
makes to deaths from other causes. Figure 5-B illustrates the
Global Trends in Malaria
Number of Cases Reported, 1974-1984
World (excl. Chino, Africa)
10
9
8
6
5
2
0
1974 1976 1977 1978 1979 1980 1981 1982 1983 1984
Years
Source: WHO/Molaria Action Programme
Demographic Data for Development Project
28
dramatic results of a controlled insecticide program in
Kenya. Two comparable villages in a heavily infested area
were selected for this study. In one village, the interior walls
of the houses, where the indigenous species of mosquitoes
rest before feeding, were sprayed regularly with insecticide.
No spraying was done in the control villages. Over a 5-year
period, general mortality in the treated village declined by
half and infant mortality was reduced by 40 percent in
comparison to the control village. Although the health
benefits from programs of this sort have proved difficult to
sustain without commensurate progress in health care ser
vices and general development, they are a clear indication
of the potential of malaria control to enhance health status.
GLOBAL IMPACT ON CHILD SURVIVAL
More than half of the world’s population lives in areas
where malaria is still endemic. About a fifth, largely in
developed countries, live in areas where malaria has been
eradicated. The credit for this achievement belongs to a
combination of socioeconomic development and special
programs that succeeded in arresting the transmission of
malaria. Antimalarial activities in most of the regions where
malaria is endemic have significandy reduced onceuncontrolled levels of transmission. Yet an important
minority of the world’s population—largely located in SubSaharan Africa—continues to suffer the full effects of un
controlled malaria. Control efforts in these areas have pro
ved either too difficult or too cosdy to maintain. Active pro
grams to fight malaria have yielded tangible gains, but they
have failed to eradicate the disease from those areas where
it is most deeply entrenched. Consequendy, any slowdown
in the battle against malaria could result in its rapid
resurgence to uncontrolled levels.
Global trends in malaria, as shown in figure 5-C, reflect
an unstable equilibrium. The total number of reported
malaria cases declined between 1977 and 1983, with a
slight upturn for the latest year reported (1984). Regional
trends, however, present a pattern of mixed success. Much
of the world decline comes from effective antimalarial cam
paigns in the Asia region. The most significant reductions
occurred in India and China, which together account for
56 percent of the world population at risk.
By contrast, the malaria situation in the Americas region
as a whole has steadily deteriorated during the last decade.
The major negative factors underlying the rise in reported
malaria cases include the introduction of malaria to newly
populated areas, the increasing resistance of malaria to in
secticide and drug treatment programs, and financial pres
sures that threaten funding for costly antimalarial activities.
The experience of the Near East testifies to the dangers
of complacency in the struggle against this disease. During
the early 1970s control efforts appeared to be successfully
Figure 5-D
Regional Trends in Malaria: Number of Cases Reported, 1974-1984
Asia
Latin America and Caribbean
0.9
</>
a
O
o
Total Asia
—■ China
—— India
12
1.0
10
0.8
V)
9
o
O
0.7
8
B 6
c
= 4
0.6
§ °-5
s
| 0.4
2
■■■■■■■■
0.3
0.2
0
■■■■■■■■■Hi
1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
Near East
Africa*
0.45
0.4
0.35
7
3 6
g 0.3
3
w 0.2
2
s 0.1
\
= 015 MM-
_\
__ ___
/
xy
o ■■HiHHHIHHHffiHHiniBnnH
1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
I
I
o
o 0.25
o 5 X
o
4
c
o
= 3
S2
/
ss
S
1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984
Source: WHO/Moloria Action Programme data, adapted to correspond to USAID regions.
' Patterns may result from unreliable reporting
Demographic Data for Development Project
reining in malaria in this region. A sudden resurgence in the
last half of the decade, however, dampened prospects for
early eradication. Turkey provides a case in point.
Antimalarial programs there had contained malaria at low
levels, but the conditions for epidemic malaria persisted.
When the malaria parasite was reintroduced into heavily
populated areas where control measures had lapsed, the
result was an explosive epidemic. The number of reported
cases nearly quadrupled each year for 3 years, rising from
fewer than 3,000 in 1974 to some 115,000 by 1977.
SubSaharan Africa continues to be the primary focus of
malaria in the world today. Of the 421 million inhabitants
of this region, 372 million live in areas where malaria is
endemic, more than half of them in hyperendemic areas
where transmission is constant and intense. The quality of
the malaria reporting is generally so poor that no real trends
for the African region can be discerned from the informa
tion available, but there appears to have been little im-
provement in the malaria situation in this region.
A new and ominous development has also begun to
hamper control efforts: current achievements are being
challenged by the appearance of new drug-resistant strains
of malaria and insecticide-resistant mosquitoes. Reports of
malarial infections that do not respond to the standard
chloroquine treatment are becoming increasingly wide
spread. Resistance to the second line of drug defense, fansidar, has been reported in South East Asia and South
America. Similarly, the effectiveness of insecticides that
once served as powerful weapons against malaria is being
threatened by the emergence of malaria-carrying mos
quitoes that have become resistant to one or more of the in
secticides currently in use. Often-indiscriminate
agricultural spraying practices have been implicated in this
new threat to existing control activities. These drug and in
secticide resistance problems make the development of
new control techniques an urgent issue.
29
THE ROAD TO HEALTH
The key to controlling malaria lies in interrupting the in
teraction between human and mosquito. The two principal
strategies of malaria control are 1) to target the mosquito
vector of malaria and 2) to arrest the parasite cycle within
humans.
Vector-control programs represent only the latest battle
in the historic war against malaria. Development of power
ful insecticides such as DDT was once expected to pave the
way for eradication of the disease. Insecticides do in fact
deserve much of the credit for reducing the worldwide toll
of death and suffering attributable to malaria, but it is now
clear that excessive reliance on this method of control gives
limited results at best and at the same time fosters insec
ticide resistance.
Experience has demonstrated the greater effectiveness of
balanced campaigns that combine chemical control with
environmental measures to limit breeding sites and reduce
human exposure. The possibilities here are vast. En
vironmental control strategies can be tailored to local com
munities and local mosquito species. And simple educa
tion for malaria prevention can tap into a powerful yet often
overlooked resource: peoples’ ability to take care of
themselves.
The other principal strategy against malaria consists of
fighting parastic infection. Antimalarial drugs, especially
the compound chloroquine, have been the mainstay of
treatment and prevention programs. The provision of anti-
30
malarials for curative purposes represents the simplest level
of malaria control. This strategy, which is common in SubSaharan Africa, has little effect on the transmission of
malaria, but does reduce mortality from severe infections.
Regular periodic doses can also be used to prevent malarial
infection. As with insecticides, however, the broad use of
these drugs to prevent malaria represents a double-edged
sword in terms of promoting the evolution of resistant
strains of the parasite. Recent research has yielded a new
crop of antimalarial drugs. One of these, mefloquin, has
proven effective against the most dangerous form of the
disease and is in the final stages of testing. The Chinese
have been studying a drug called qinghaosu, which is
derived from an ancient herbal remedy for malaria. Re
searchers hope that rational use of these new treatments
can either prevent drug resistance or delay its advent.
A new weapon against malaria may soon be added to the
existing arsenal: a vaccine against the first stage of malaria
infection may be available within the next decade. Primates
immunized with a test vaccine have successfully resisted
a direct “challenge” by the malarial parasite. Field trials are
presently under way and research on vaccines for the
additional stages of malaria is in progress. Questions as yet
unanswered about a malaria vaccine include its cost, the
duration of its protection, and whether it can be given to
young children. Authorities caution against the expectation
that a malaria vaccine will be the “magic bullet” that can
replace other control efforts. Nonetheless, a vaccine pro
mises to be an important addition to ongoing programs
against malaria.
VI. MALNUTRITION
PROFILE
Malnutrition is in many respects the common denomi
nator of the disease and deprivation processes that reduce
child survival. Undemutrition affects nearly 40 percent of
all children in developing countries and contributes direct
ly or indirecdy to an estimated 60 percent of all child
deaths. Lack of food is only part of the problem. Disease
itself is a principal agent of child malnutrition. A heavy
burden of infection places a formidable strain on what may
already be a precarious nutritional balance. As a result, the
child is left with a nutritional debt that causes dangerous
lags in growth and further vulnerability to the cycle of
disease and malnutrition. Another major factor in
malnutrition is human behavior. Feeding practices, for ex
ample, especially during illness, can make the difference
between normal growth and malnutrition, or even between
life and death.
Protein-Calorie Malnutrition
Malnutrition can result from a dietary deficiency in any or
all of the three major nutrient groups: proteins, calories,
and micronutrients such as vitamins and minerals. Protein
calorie malnutrition is by far the most common type of
malnourishment. It occurs when a child’s total protein and
energy intake becomes inadequate for normal growth. A
child is considered to have protein-calorie malnutrition if
his weight falls below the critical level of 80 percent of the
standard median weight for his age group. Below this level,
the child’s risk of death increases exponentially. The graph
in figure 6-A shows the experience of children under age
3 in Punjab, North India. Their probability of death was
found to nearly double with each 10 percent drop in
weight-for-age below the 80 percent level.
The most severe levels of protein-calorie malnutrition are
kwashiorkor and marasmus. Although they represent only
a small part of the malnutrition picture, these extremes
have become familiar to television audiences as a result of
coverage of recent disasters in Africa. The flaky skin, thin
ning hair and swollen bellies of child victims are symp
tomatic of kwashiorkor. It results from a reduction in pro
tein metabolism relative to calories that can be precipitated
by a chronic dietary imbalance or a severe infection such
as measles. Marasmus is characterized by a state of emacia
tion seen most frequently among famine victims. It occurs
when protein and calories are equally and drastically defi
cient from the diet. Children cannot survive long in either
of these states. Without improvement, death comes
quickly.
Figure 6-A
Risk of Death by Nutritional Status:
Children Age 1-36 Months, Punjab, India
12%
o
Q.
O>
6%
a
4.5%
o
O
1.2%
Less than 60
60-69
70-79
80+
Percent of the Median Standard Weight-for-Age
Source: Keilmonn, A.A., C. McCord 'Weight-for-Age os on Index of Risk of Death in
Children," Lancet, June 10,1978.
Demographic Data for Development Project
Vitamin A Deficiency
Although micronutrients are only required in minute
quantities, their absence from a diet can carry severe con
sequences. Of the many vitamins and minerals essential to
a balanced diet, vitamin A, iron, and iodine play especially
prominent roles in child survival. Vitamin A deficiency has
long been recognized as the leading cause of childhood
blindness in the world. Now, however, there is evidence
that the impact of vitamin A deficiency on a child begins
well before it induces blindness. Indonesian children
manifesting mild symptoms of vitamin A deficiency were
found to be at 3 times greater risk of illness and 4 to 12
times greater risk of death than children with no outward
symptoms. The presence of these mild symptoms was
more closely associated with subsequent illness and death
than even the presence of protein-calorie malnutrition.
Iron and Iodine Deficiencies
Iron deficiency is the leading cause of anemia, an ex
hausting disease that affects more than half of all children
and pregnant women in the developing world.
Iodine deficiency causes goiter in adolescents and adults
but is rarely seen in children. It becomes an especially
i
I
31
serious issue for child survival when it affects pregnant
women. Children bom to iodine-deficient mothers are at
risk of being mentally retarded to some degree. The most
serious outcome is cretinism, where the child is bom deafmute, mentally retarded, and shows abnormal motor
development.
IMPACT ON CHILD SURVIVAL
Low Birth Weight
The road to health for a child begins before birth. In
developing and developed countries alike, the birth weight
of an infant is the most important single determinant of its
chances for survival. Low birth weight infants—those who
weigh less than 2,500 grams (5.5 pounds) at birth
experience higher mortality from all causes through the
first year of life and beyond. Figure 6-B depicts the pattern
of decreasing risk with increasing birth weight The data are
drawn from births in the state of Massachusetts. While
death rates for infants bom in developing countries are cer
tainly higher at all points, the dramatic rise in mortality
below 2,500 grams occurs in all regions.
Of the many factors that influence the incidence of low
birth weight, the most common relate to the nutritional
state of the mother both before and during pregnancy. A
Figure 6-B
Infant Mortality by Birth Weight
State of Massachusetts: 1972
85.2%
O)
®
CQ
OJ
43.7%
</>
2<
o
14.8%
s<5
3.3%
1.0%
0.47% 0.49%
Q-
500
1000
1500
2000
2500
3000
4500
Birth Weight in Grams
Source: Friede, A.M., S. Becker, P.H. Rhodes, "The Comparison of Infant Mortality
Rates When Birthweight Distribution Differs," Proceedings of the 1985
Public Health Conference on Records and Statistics, Hyattsville, MD„
Public Health Service, 1986: p. 370-374.
Demographic Data for Development Project
32
Feeding Patterns
The impact of nutrition on the survival of a child is general
ly considered in two time frames, the period of exclusive
breastfeeding which optimally extends 4 to 6 months from
birth, and the subsequent weaning period, when the diet
of breastmilk begins to be supplemented with other foods,
which extends to the end of the third year. Good nutrition
during the child’s first 6 months is especially critical. An in
fant’s weight should more than double during this period,
when the rate of growth is faster than at any other period
in life. A child’s health is particularly sensitive to interrup
tions in growth at this time, whether they result from inade
quate nutrition or from a heavy burden of infection. Nature
provides both a balanced diet and important protection
from disease in the form of breastmilk, as noted in The
Road to Health section, which follows. The importance of
breastfeeding cannot be overemphasized. In areas where
there are no viable feeding alternatives, infants who are
weaned early or never breastfed at all are at significandy
higher risk of illness, malnutrition, and death.
Weaning
p
Q
woman’s caloric needs increase during pregnancy and rise
to still higher levels when she breastfeeds. For many
women in areas where fertility is high, there is barely time
to recover the nutritional debt from one pregnancy and
breastfeeding experience before the next one begins. The
problem is intensified by heavy physical workloads during
pregnancy, maternal malnutrition, numerous pregnancies,
and short birth intervals, all of which are important risk fac
tors for low birth weight. Whatever the root cause, a low
birth-weight infant faces an uphill battle. He is already
malnourished when his life begins.
Beyond the age of 6 months, breastfeeding alone will not
meet the nutritional needs of a growing infant The weaning
period is a critical passage during which the child
establishes greater independence from his mother. The
price of that independence is greater exposure to the out
side environment and its attendant agents of disease and
malnutrition. His new supplemental diet introduces the
child to common contaminants in food and water, and
greater mobility brings him into contact with a range of
new diseases carried by other children and adults. At the
same time, the passive immunity inherited from his
mother, which protected the child from many of these
diseases in the first months of life, has begun to decline. As
a result, the weaning period is marked by frequent illness.
Respiratory and diarrheal diseases increase sharply. In
developing countries, the major contagious diseases of
childhood (e.g., measles, pertussis) also tend to converge
at this time.
Regional Pattern of Acute Protein-Calorie Malnutrition
Median Prevalence of Low Weight-for-Height (Wasting) by Age
i------ 1
I___ I Africa
Latin America
& Caribbean
Near East
Asia
17.9
12.5
ix
7.6
o>
6.1
q
2
a>
6.0
6.6
3.9
4.8
3.8 j
2.6
1.6
4.8
7.0
2.0
3.8
3
2
Under 1 year
Age in Years
Note:
Points represent regional medians tor each age group. Data were available for 25 countries.
Source: Keller, W., C.M. Fillmore, "Prevalence of Prolein-energy Malnutrition," World Health Statistics Quarterly, 36(2), Geneva, Switzerland, 1983.
Demographic Data for Development Project
Nutritionally, the child switches from a diet that is
biologically determined to one that is socially determined,
often to his detriment. Traditional weaning diets frequently
lack sufficient quantities of essential nutrients, particularly
protein, vitamin A, and iron. Sometimes the problem is an
absolute lack of food. More often, however, available foods
that contain these elements are not considered “appro
priate” for young children. Foods for young children need
to have more calories per given amount, because while
children’s caloric needs are high, their stomachs are small.
They cannot consume as much as adults, and therefore
have difficulty in meeting energy needs from normal adult
foods. For their part, children often have their own ideas
about what is appropriate to eat. Foods high in protein and
vitamin A are often excluded from weaning diets. As a
result, children are at higher risk of malnutrition during the
weaning period than at any other time. The regional pat
terns of acute protein-calorie malnutrition depicted in
figure 6-C show a dramatic peak around age 1, which cor
responds to the midpoint of the weaning period. Acute
protein-calorie malnutrition, or wasting, is measured by the
ratio of a child’s weight to his or her height. Below 80 per
cent of the median weight for healthy children of the same
height, a child is said to be acutely malnourished. This
measure is considered to be a sensitive indicator of a child’s
immediate nutritional status and health risk. The problems
of vitamin A deficiency and nutritional anemia also reach
their highest levels in early childhood. The impact of poor
weaning practices and heavy burdens of infection is seen
in the high yearly toll of deaths in this age group.
The Disease-Malnutrition link
The strong interaction between disease and malnutrition
stems from both biological and social causes. Biologically,
many diseases raise a child’s metabolic rate and hence his
food requirements. Certain parasitic organisms actually
compete with the child for ingested food, and diarrheal
diseases work to inhibit food absorption. Very often
diseases occur together, posing a serious challenge to the
needs of a child who may already be limited to a sub
sistence diet. On the individual level, the child’s loss ofap-
33
THE GLOBAL MAGNITUDE OF
MALNUTRITION
petite is apt to further limit food intake. On a social level,
when a child becomes sick, the parental response may be
to stop regular feeding, which results in further deteriora
tion of the child’s nutritional status.
As disease can precipitate malnutrition, so malnutrition
can complicate disease. Deprived of essential nutrients, the
body loses its normal ability to resist disease. Both the
severity and duration of disease have been shown to
increase in moderately and severely malnourished
children. Consequently, mortality from common com
municable diseases is far higher among children in poor
developing populations than among children who receive
adequate diets.
The synergism of disease and malnutrition—the tenden
cy of these conditions to complement and intensify each
other when combined—is an important factor in child sur
vival. At a critical level of growth retardation and disease
burden, this synergism establishes a vicious cycle that
culminates in death. It has been estimated that malnutri
tion is a contributing factor in 60 percent of all infant and
child deaths in the developing world.
The world has made significant progress in the battle
against hunger over the last two decades. Many countries
that were once periodic victims of famine have now
become net food exporters. India is an example of such a
country (see the section on Food Availability). This pro
gress is reflected in a general decline in infant and child
mortality during this period, but much remains to be done.
In the developing world today, it is estimated that nearly 40
percent of all children under 5 suffer from acute or chronic
protein-calorie malnutrition. In absolute numbers, this
translates into 141 million children in 1980. Figure 6-D
shows the estimated regional prevalence of this condition
among children. More than one-third of African children
fall below 80 percent of their expected weight-for-age, as
do almost half of children in the Asian region. The
estimated prevalence is lower in Latin America and the
Near East at 21 and 24 percent respectively. Because of
Asia’s large population size and high proportions of
Figure 6-D
Estimates of Childhood Malnutrition in Developing Regions, 1980
Number and Percent of Children Age 6 to 60 Months
Above and Below 80 Percent of the Median Standard Weight-for-Age
Malnourished children
Normal children
38.0 million (64.9%)
20.6 million (35.1%)
Africa
10.6 million (24.6%)
32.7 million (75.4%)
Near East
—
bl
__________
Asia
99.1 million (48.3%)
106 million (51.7%)
43.4 million (78.9%)
11.6 million (21.1%)
Latin America & Caribbean
100
80
60
40
20
0
20
40
60
80
100
Number of children in millions
Malnourished children
Normal children
Note:
Low weight-for-age may reflect current, acute malnutrition, the accumulated effects of chronic and acute malnutrition or both. It does not necessarily represent an immediate
health risk.
Source: Adopted from Hoaga, J. C. Kenrick, K. Test, J. Mason, "An Estimate of the Prevalence of Child Malnutrition in Developing Countries," World Health Statistics Quarterly, Table 38,
Geneva, Switzerland, 1985.
Demographic Data for Development Project
34
Figure 6-E
Percent Low Birth Weight
U.S. and Developing Regions, 1982
27.0
O)
a*
=:
<5
J
o
10.1
8.3
6.9
Africa
Near East
Asia
Latin America
&
of newborns nonetheless accounted for two-thirds of U.S.
deaths in the first month of life and 20 percent of infant
deaths from 28 days to the end of the first year.
Each year more than a half-million children become
blind for lack of vitamin A; two-thirds die within weeks of
losing their sight. Another 6 to 7 million children are
believed to suffer from milder forms of vitamin A defi
ciency, which has been identified as a significant public
health problem in 21 developing countries.
Iron deficiency anemia most often affects women of
childbearing age and young children. Pregnant women are
the most susceptible. Although this is true for both
developed and developing countries, anemia in the
developing world is 4 to 5 times more frequent. Frequent
infections and deficient diets consign more than half of
developing country children to the draining effects of
anemia. More than 60 percent of pregnant women are
affected in Asia and Africa. This reflects the greater iron re
quirements of women in general and especially of pregnant
women, whose needs are likely to be increased in develop
ing countries by iron-poor diets and parasitic infections.
U.S.
Caribbean
Source: Adapted from World Health Organization, "The Incidence of Low Birth
Weight: An Update," Weekly Epidemiologic Record, 59(27): 205-212,
Geneva, Switzerland, 1984.
Demographic Data for Development Project
underweight children, some 70 percent of the world’s
malnourished children are found in this region.
The high global prevalence of malnutrition is especially
astonishing in view of the fact that the estimates were made
from data based around 1980, when the world was relative
ly free of famine. These children are the victims of the per
sistent diseases and sometimes subde nutritional depriva
tion that act under “normal” conditions of poverty. Such
severe and deadly forms of protein-calorie malnutrition as
marasmus and kwashiorkor are in fact relatively rare if
highly visible extremes of a much more pervasive problem.
As a closely related precursor of protein-calorie malnutri
tion, low birth weight follows the same geographic pattern.
In figure 6-E, the regional percentage of all births under
2,500 grams (5.5 pounds) is shown for 1982. The problem
is severest in Asia where an estimated 27 percent of infants
bom in 1982 were below this weight. In India, which
accounts for more than half of births in this region, ex
cluding China, 30 percent of newborns were critically
underweight, as were fully half of infants in Bangladesh.
African countries report between 10 and 20 percent
underweight births, with an average of 15 percent. By con
trast, fewer than 7 percent of all infants bom in the United
States weighed less than 2,500 grams. This tiny proportion
THE ROAD TO HEALTH
The ultimate resolution of the problem of global malnutri
tion lies in a people’s ability to feed themselves. Short-term
relief efforts play a lifesaving role during extreme cycles of
famine, but food scarcity issues can only be permanently
resolved through long-term economic development.
In this context, however, it is important to recognize that
simple measures to improve health and feeding practices
can be expected to have a significant impact on malnutri
tion and child survival while long-term development is
proceeding.
Improved Health and Nutrition
During Pregnancy
Prevention of low birth weight is the first step on the road
to health. A number of possible courses of action can
reduce the risk of low birth weight. Both reducing heavy
workloads during pregnancy and providing dietary supple
ments to women at high risk act to diminish the nutritional
strains of pregnancy. The strong association between highrisk fertility and low birth weight underscores the impor
tance of family planning in preventing low birth weight and
improving maternal and child health.
Breastfeeding
The nutritional value, anti-infective properties, and birth
spacing effects of breastfeeding make it one of the most
powerful forces for enhancing child survival. Nutritionally,
breastmilk provides the optimal balance and quantity of
essential nutrients to infants up to 6 months of age. Even
35
after supplementation with other food has begun, breast
milk can continue to be an important source of calories,
protein, and micronutrients through the second year of life.
Alternative feeding methods can by contrast only approx
imate the nutritional completeness of mothers’ milk, and
cannot impart the additional benefits that breastfeeding
brings to both mother and child.
Breastfeeding and Disease: Breastmilk has an ideal
nutritional balance and also contains anti-infective proper
ties that help protect the child from early exposure to a
disease-ridden environment. Breastmilk is sterile and
passes directly from mother to child, virtually eliminating
the possibility of contamination. This point is far from
trivial in areas where food- and water-borne diseases are a
major cause of sickness and death. Moreover, breastmilk
contains maternal antibodies, enzymes, and other chemical
properties that actively resist infection. Numerous studies
have found that breastfed infants experience lower levels
of mortality and fewer episodes of gastrointestinal and
respiratory illness than infants in the same environment
who are only partially breastfed or not breastfed at all.
Figure 6-F shows that in rural Chile, exclusively breastfed
infants experienced half the mortality of botde-fed infants,
while mortality of infants who were both breastfed and
botde-fed ranged in between. Regardless of the time period
examined during the first year, mortality rates for infants
who were exclusively bottle-fed were twice those of ex
clusively breastfed infants. The anti-infective properties of
breastmilk clearly play a crucial role in enhancing child
survival in a hostile disease environment.
Birth Spacing: An additional benefit of breastfeeding in
the context of child survival is the important contraceptive
effect it has on the mother, improving the chances of sur
vival for both the newborn and the child that follows.
Breastfeeding prolongs the anovulatory period that follows
childbirth during which a woman is naturally protected
against a succeeding pregnancy. The extent of contracep
tive effect depends on the frequency, duration, and inten
sity of breastfeeding. Women who breastfeed regularly from
the time of giving birth can extend this protective interval
over 1 to 2 years. In many parts of the developing world,
breastfeeding has a greater impact than any other con
traceptive method in promoting healthful birth-spacing.
The importance of birth-spacing to child survival is ex
amined in detail in the section on high-risk fertility.
Breastfeeding Promotion
In many areas of the developing world, prolonged
breastfeeding continues to be the rule. Its prevalence is
generally highest in poorer, rural areas. Within the last 10
years, there has been a dramatic resurgence in rates of
breastfeeding in the developed world as awareness of its
natural benefits has grown. Among women in developing
countries, however, the trend has been away from
36
Figure 6-F
Mortality for 3 Different Time Periods
During First Year of Life By Source
of Milk: Rural Chile
Breastfed only
Breast and bottle
Bottle-fed only
6.1%
—
Ir___
5.6%
3.9%
_______
o>
3.8%
a
2.0%
S
a>
2.9%
1.4%
1.4%
1.0%
Mortality
Mortality
Between 1 Month
Between
and 1 Year
3 Months and
1 Year
Mortality
Between
6 Months and
1 Year
Source: Adapted from Plank, S., M,
M. Milanesi, “Infant Feeding and Infant Mortality in
Rural Chile," Bulletin of the World Health Organization, 48: 201-210, Geneva,
Switzerland, 1973.
Demographic Data for Development Project
breastfeeding, particularly in urban areas. Given the high
fertility and poor health conditions that still characterize
these areas, a decline in breastfeeding poses a serious threat
to improvements in child survival. It is estimated, for ex
ample, that if breastfeeding patterns in Bangladesh were to
fall to U.S. levels, infant mortality there would double.
The promotion of breastfeeding to counter this trend has
become an important aspect of child survival programs.
These generally take three forms: information and support
programs in the community, training programs for health
professionals, and efforts to change hospital practices to en
courage new mothers to begin breastfeeding. Information
programs have enlisted the support of the media and the
medical profession to get the message of breastfeeding’s
unique benefits across. In modem hospital settings, the
decision to breastfeed is often influenced by hospital prac
tices and the advice of health professionals in the first few
days following birth. Women who are allowed to room-in
with their newborns appear to be more likely to start
breastfeeding, which both fosters intimacy between mother
and child and increases the likelihood that the mother will
continue to breastfeed. Figure 6-G shows the results of an
intensive breastfeeding promotion program in Costa Rica.
Rural hospitals that instituted a rooming-in policy wit
nessed a significant rise in the number of mothers breast
feeding at birth and during the child’s first year. When
rooming-in and other activities were undertaken to en
courage breastfeeding, another hospital program recorded
a 75 percent drop in neonatal mortality rates over 5 years,
mostly from a decrease in diarrhea deaths.
Improved Weaning Practices
The promotion of careful weaning practices is another im
portant health intervention. The extent of risk incurred in
the weaning transition depends on when it begins and how
abruptly it ends. Gradual weaning is safest for the child. As
he grows accustomed to a supplemental diet, he still enjoys
a level of disease protection from breastmilk and receives
the benefits of an important source of proteins, calories, and
vitamins. In fact, breastmilk may provide the major source
of such essential nutrients as iron and vitamin A when they
are lacking from weaning foods. In a hostile disease en
vironment, early and abrupt weaning has serious health
implications for the child. Sudden cessation of
breastfeeding can occur if the child becomes sick or the
mother becomes pregnant again. Deprived of a gradual
transition, the child must adjust to a new diet, increased ex
posure to disease, and loss of immune protection all at
once. The younger the child, the more dangerous such
abrupt weaning becomes.
Healthy weaning means insuring that the child’s new diet
contains die nutrients necessary to sustain normal growth
and development. Efforts to ensure healthy weaning vary
from providing direct food supplements to pre-school
children to simple education and the promotion of lowcost, locally available weaning foods. A single vitamin A
capsule costs as little as 2 cents and can protect a child
against blindness and probably other illness for a full 6
months. In the case of micronutrients like iron and iodine,
programs at the national level to fortify common foods sold
in markets provide more comprehensive protection.
Figure 6-G
Impact of Breastfeeding Promotion
Two Examples from Costa Rica
Impact of Rooming-in on Level and
Duration of Breastfeeding
Two Rural Hospitals in Costa Rica
Impact of Breastfeeding Promotion on
Neonatal Mortality
□
Q Roomlng-ln
| H No Roomlng-ln
Diarrhea
|
| Other
] Lower Respiratory Infection
11.8 I
O>
5
2 —
«- w
78%
77%
52%
CQ
fl
Oo
fg
55
♦—
■ i
5.2
v> i>_
E 03
CD
4-7
Age in Months
4.6
3.9
10%
0-3
9
7
oo
35%
S
<] Breastfeeding
Promotion
Started, 1977
§
86%
a>
12.7
0
1.2
8-11
1976
1977
1978
1979
1980
Years
Source: Moto, L, et al., "Promotion of Breast-Feeding, Health, and Growth among Hospital-Born Neonates, and among Infants of a Rural Area of Costa Rica," Diarrhea and Malnutrition, L.C.
Chen, N.S. Scrimshaw (ed.) Tokyo, Japan: Plenum Press, 1983, pp. 177-203.
Demographic Data for Development Project
37
Figure 6-H
The Road to Health: Model Growth Chart
18------------------------------------------------- --------------
• A
04
120%
16
Prolonged Diarrhea
14
Measles
</)
o>
a>
80%^
o
o
S
o
Abruptly Weaned
I
ORT/
Extra Feeding
2 8
O)
aS
2
60% S
o
ORT/
Extra Feedir g
6
4
0>
<o>
o
Diarrhea/
Cough
12
|10
=
Diarrhea/
Cough
Diarrhea
Protein Calorie
Malnutrition
\
Special
Supplementary
Feeding Begins
Special Care Started
25 26 27 28 29 30 31 32 33 34 35 36
Breastmilk Only
13 14 15 16 17 18 19 20 21 22 23 24
D'
Birth 1 2 3 4 5 6 7 8 9 10 11 12
MONTHS
This child is breastfed from birth and starts normal growth. But his weaning begins late and ends abruptly. When measles strikes,
followed by a prolonged case of diarrhea, weight loss becomes critical. Brought into a clinic with protein calorie malnutrition, the child
starts a special program, receiving dietary supplements and immunization, while his mother learns simple techniques for ORT and
disease prevention. Even with occasional infections, the child's growth rebounds and within a year he is back on the road to health.
Demographic Data for Development Project
Feeding During Illness
Repeated illness need not result in serious growth lags and
malnutrition. The importance of continued feeding
through disease episodes must be stressed, especially when
the conventional wisdom calls for withholding food. Even
when feeding is continuous, a child can lose weight from
serious or prolonged infection. Extra feeding is essential to
fuel a child’s “catch-up growth” during the recovery period.
Growth Monitoring
Growth monitoring is one of the cornerstones of global
strategies to improve child survival. When periodic
38
measurements of weight are recorded on a growth chart
over time, the chart provides a progress report of a child’s
growth and development from birth. The “road to health”
charted by the upper and lower lines in figure 6-H describes
the normal range of weights for healthy children from birth
to age 5. A child who enjoys steady weight gain and can stay
between these lines has greatly improved his chances for
survival over those of a child who slips below the lower
limit into malnutrition. The chart is a sensitive indicator of
pauses or lags in growth over time. Regular measurements
can alert parents to the dangers of undemutrition and the
need for additional feeding.
vn. HIGH-RISK FERTILITY BEHAVIOR
PROFILE
Three aspects of childbearing have an important effect on
child survival beyond the risks posed by malnutrition, in
fection, and lack of health care. They are the mother’s age
at birth, the number of children she has previously borne,
and the length of time between births. Of these factors, the
birth interval appears to have the greatest impact on child
survival. A child who is bom soon after another child, or
whose birth is rapidly followed by another birth, has a
much greater chance of dying. Many children are placed in
double jeopardy by being bom between two short intervals.
Short intervals are 2 years or less, a time period that gives
a mother at most little more than a year to breastfeed, to
recover from the physical and nutritional strains of
pregnancy and breastfeeding, and to prepare for the next
child. The shorter the interval the greater the risk to the
child. By the same token, when 1, 2, or 3 years are added
to the interval, the child’s survival chances tend to rise
accordingly.
Figure 7-B
Percent of Children Who Die Before Age 5,
When Births are Spaced at Least 2 Years Apart,
and When a Preceding and/or Following Birth
Occurs Within 2 Years
Mortality level of children born
at least 2 years apart
raHnm Increased mortality level of children born less than
2 years after another child
Increased mortality level of children born less than 2 years
after another child, and then closely followed by another child
19
Nepal
14
_
16
Peru
Lesotho
Haiti
Percent of Births Close to Another Birth
Pakistan
Asia
5
Jordan
25 29
30
Syria
24
19
21 23
9i
16
11
16
23
20
17 20
BH
'
7
16 18
10
16
17
13 14
5
13 13
BWMMB
8 12 13
Sri Lanka
Following Birth Interval
Less than 18 Months
15
10
Colombia
Latin America &
Caribbean
32
15_______ 24
Mexico
Sudan
Near East
mb
29 31
13
Philippines
Africa
32
24
11
Kenya
28%
28
BBBBBBBM^HBBB
Thailand
27%
34
14
7
Ghana
44%
29
13 “T
Ecuador
Korea
Preceding Birth Interval
Less Than 2 Years
35
25
18
Bangladesh
Figure 7-A
25
13
Indonesia
0
10
20
30
Percent of Children Dying Before Age 5
24%
Africa
Note:
21%
13%
11%
Near East
Asia
Latin America &
Caribbean
Source: Hobcraft, J., J.W. McDonald and S.O. Rutstein, “Child-Spacing Effects on
Infant and Early Child Mortality," Population Index, 49(4): 585-618, Table 9,
Princeton University, N.J., 1983.
Demographic Data for Development Project
Values are the unweighted average percent of surveyed countries in a
given region.
Source: Hobcraft, J., J.W. McDonald and S.O. Rutstein, "Child-Spacing Effects on
Infant and Early Child Mortality," Population Index, 49(4): 585-618, table 2,
Princeton University, N.J., 1983.
Demographic Data for Development Project
39
Figure 7-C
Relative Mortabty Levels of Children Bom to Mothers of Different Ages
150_ Infant Mortality
Second Year Mortality
147
140—
O)
I Relative mortality level at children
130-
i_ CD
CD CD
r
120—
122
no—
o2
2o
100-
ss
90—
o2
80-
105
LU c
CD
7060—
SO19 or younger
20 to 29
30 to 39
Age of Mother
40 or older
19 or younger
20 to 29
30 to 39
Age of Mother
40 or older
Note: Values are unweighted averages of 41 countries.
Source- Rutstein, S.O., “Infant and Child Mortality: Levels, Trends and Demographic Differentials," Revised Edition, World Fertility Survey Comparative Studies No. 43, Table 12, International
Statistical institute, Voorburg, Netherlands, 1984.
IMPACT ON CHILD SURVIVAL
Time Between Two Births
Short birth intervals are a universal health risk. Children
bom in quick succession are at greater risk of dying in every
region of the world, in both urban and rural areas, and in
countries at all levels of mortality. Moreover, close birth
spacing increases mortality in families at all socioeconomic
levels, even those in which the parents are wealthy and
well-educated. The adverse effects of close spacing afflict
children bom to women of all ages, and children of all birth
orders. Children of every circumstance are disadvantaged
by being bom less than two years apart Sustaining a longer
interval between births provides a simple preventive
measure against a major hazard.
Short intervals between births affect many children. By
not spacing births, a woman reduces the survival chances
of both her young infant and her next child. It is common
in many developing countries for women to bear children
in rapid succession, and where fertility is high, most
children will have both an older and a younger sibling.
Figure 7-A shows regional proportions of children who are
bom soon after another child, and whose arrival is quickly
followed by the birth of yet another child. In some coun-
40
Demographic Data for Development Project
tries nearly half of children are bom less than 2 years after
an older sibling, and one-fourth do not reach their first
birthday before their mother becomes pregnant again.
Many of these children find themselves in double jeopardy
when they arrive between two close births. In looking at the
dangers of close spacing, and the numbers of children sub
ject to such risk, it is possible to estimate the number of
deaths attributable to this cause. During 1986 approxi
mately 2 million children under 5 will die because of
hazards associated with rapid childbearing. It is estimated
that, on average, 1 in 5 infant deaths could be averted by
longer intervals between births.
Maternal depletion: The detrimental effect of inadequate
intervals between births has a number of causes. Because
women who bear children rapidly do not have adequate
time to recover from the demands of a prior pregnancy and
breastfeeding, they become nutritionally and physically ex
hausted. Maternal depletion syndrome, as this exhaustion
is called, may cause the birth of premature, underweight in
fants and result in inadequate breastmilk, both of which are
major health risks.
Premature and abrupt cessation of breastfeeding: The
onset of another pregnancy soon after the birth of a child
is likely to cause him to be weaned long before he should.
Studies have shown that abmpt and premature cessation
of breastfeeding is a major risk to the health of young
children, particularly when it coincides with a pregnancy.
Competition: Children close in age are placed in com
petition with each other for the same maternal and familial
resources. Individual parental time and attention are
necessarily lessened, and family resources, including food,
must be stretched further. Competition for family resources
appears to be more critical among 2-,3-, and 4-year-olds
than among children under two. This is seen in the feet that
only beyond age 1 is excess mortality lessened when a close
sibling dies.
Maternal mortality: Women who bear children in close
succession are deprived of time needed to recover from the
demands of pregnancy, labor, and breastfeeding. Exhaus
tion and higher rates of complications increase their risk
of death and jeopardize the survival chances of their
children.
Related risks: A number of factors intervene to prevent
clear understanding of why a short interval between births
is such an impediment to survival. For example, some
households may have conditions that affect all children—a
common cause that reduces their survival chances. The
death of a child may spur an early new pregnancy to re
place the lost child. The newly bom child, arriving after a
short interval, is then likely to be exposed to the same fac
tors that killed the first child. Women who breastfeed all of
their children briefly (for such reasons as disinterest or the
need to work) place each child at a disadvantage, and
resume ovulation sooner than those who continue to
breastfeed. Brief breastfeeding duration both decreases sur
vival chances and shortens the interval to the next concep
tion. Although death rates are higher for children of teenage
mothers, who are highly likely to have closely spaced
births, high child mortality is correlated with short birth in
tervals in all age groups.
Magnitude of the risk: In studies of data collected by the
World Fertility Surveys (WFS), the mortality of children
bom at least 2 years apart is compared with that of children
born in more rapid succession. In every country mortali
ty rates are higher for children with a close prior birth; in
half of the countries infant mortality rates are more than
double for these children, irrespective of whether a subse
quent birth follows. If births are spaced as closely as 3 births
within 2 years, first-month mortality triples in more than
half of the countries. The effect of a close prior birth con
tinues beyond age 1, though with lessened severity.
When a child’s birth is quickly followed by another birth,
the risk of death during age 1 is often doubled, and the risk
of death during ages 2, 3 and 4 often increases by 50 per
cent. Figure 7-B shows mortality from birth to age 5 for
well-spaced children and increased mortality associated
with short prior intervals, and associated with both short
prior and subsequent intervals. On average, the mortality
of children bom soon after another child is 80 percent
Figure 7-D
Percent of Women Age 20-24
Who Had at Least One Birth as a Teenager
Bangladesh
80
Jamaica
Java and Bali
51
Pakistan :-----
---^^3 49
i 47
Nepal
Dominican Republic =--------
44
Jordan =
44
Mexico
41
Guyana
40
Colombia
37
Panama
36
Costa Rica ■^^34
Fiji
30
Thailand
i 26
Malaysia ■MH 25
Peru ■—■^—23
Philippines MMM22
United States*
20
Sri Lanka
Korea — j6____________________________
0
20
40
60
80
100
Percent Who Had a Teenage Birth
■ Percent of women exact age 20
Sources: Casterline, J.B. and J. Trussel, "Age at First Birth,” World Fertility Survey Com
parative Studies No. 15, Table 3, International Statistical Institute, Voorburg,
Netherlands, 1980.1984 Cohort Fertility Tables, Division of Natality Statistics,
National Center for Health Statistics.
Demographic Data for Development Project
higher, and the mortality of children born between two
short intervals more than doubles.
Age of Mother at Birth
Children bom to mothers in either very young or very old
reproductive age groups are less likely to survive. Teenage
mothers are often biologically, emotionally, socially, and
economically ill-prepared for childbearing. Mothers in
their late 30s and 40s, especially those who began
childbearing at an early age, may be less able to withstand
the stresses of pregnancy, delivery, and breastfeeding. The
effect of mother’s age is most important during the first year
of life. Beyond infancy the effect diminishes; during ages 1
to 5, levels of excess mortality decline. Figure 7-C illustrates
41
the generally observed relationship between mother’s age
and the survival of her children. Figure 7-D shows the pro
portion of women who bear a child as a teenager in selected
countries. Although older age has been assumed to be a
major determinant of child survival, some WFS data sug
gest that the combination of many births and too-short in
tervals may be the more important factor.
Number of Children a Woman has
Borne Previously
Firstborn children and those who follow many brothers
and sisters exhibit high mortality, as illustrated in figure 7-E.
Compared with children bom second or third, excess mor
tality of firstborns is acute soon after birth, but after age 1,
firstborns are no longer at a disadvantage. Mortality of
children of high birth orders is high at all ages. These
children may suffer from competition from siblings, are
more likely to be cared for by someone other than their
mother (usually an older sister), and their births are more
likely to have been considered unwanted. Though the asso
ciation between high fertility and low socioeconomic status
amplifies the disadvantage, being bom at a high order is a
mortality disadvantage at all levels of parental wealth and
education.
THE ROAD TO HEALTH
Children who are closely spaced, have numerous siblings,
or are bom to mothers in the youngest and oldest
childbearing ages are at a significandy increased risk of dy
ing. Differences in risk, particularly when births are closely
spaced, can be enormous. The global death toll from highrisk fertility among children under age 5 will probably
exceed 2 million during 1986 alone.
Fertility behavior is deeply rooted in the cultural,
economic, and political fabric of a nation. Changes in the
number of children parents desire, and in the belief that
births cannot or should not be planned, imply major
changes in family relations, the status of women, expecta
tion of life for children, and the oudook that certain aspects
of life are predetermined. Contraceptive technology exists
that can enable couples to effectively plan births. It is not
technology that is lacking, but global access to this
technology, as well as national, familial, and individual
motivation to use it. Although information and education
programs can encourage family planning, without effective
distribution and a reliable source of supplies, efforts and en
thusiasm can be undermined.
Surveys of fertility and contraceptive use in developing
Figure 7-E
Relative Mortality Levels of Children by Birth Order
Second Year Mortality
15Q_ Infant Mortality
r
140-
140
130-
CD
Relative mortality level of children
born 2nd or 3rd = 100
—1 -o
® CO
Oo
139
125
120—
no—
If 100gg
________
A
90-
LU
■SO
■o
807060-
50—
1st born
2nd or 3rd
4th to 6th
Birth Order
7th or higher
1st born
2nd or 3rd
4th to 6th
Birth Order
7th or higher
Note:
Values are unweighted averages of 41 countries.
Source: Rutstein, Shea 0„ "Infant and Child Mortality: Levels, Trends and Demographic Differentials," Revised Edition, World Fertility Survey Comparative Studies No. 43, Table 14, Interna
tional Statistical Institute, Voorburg, Netherlands, 1984.
42
Demographic Data for Development Project
Table 7-A
Percent of Married Women Age 15-44 Who Do Not Want to Become Pregnant
and Who Know About and Use Contraception
Region, country,
and year of survey
AFRICA
Benin 1981-82
Botswana 1984
Cameroon 1978
Ghana 1979-80
Ivory Coast 1980-81
Kenya 1984 +
Lesotho 1977
Mauritania 1981
Nigeria 1981-82
Senegal (rural) 1982
Sudan (north) 1978-79
Zimbabwe 1984
NEAR EAST
Egypt 1980
Jordan 1983
Morocco 1983-84
Syria 1978
Tunisia 1983
Yemen, Arab Rep 1979
ASIA
Bangladesh 1979-80
Fiji 1974
Java and Bali 1976
Korea, Rep. of 1979
Malaysia 1974
Nepal 1981
Pakistan 1975
Philippines 1978
Sri Lanka 1982
Thailand 1981
LATIN AMERICA & CARIBBEAN
Barbados 1980-81
Bolivia 1983
Brazil (northeast) 1980
Brazil (southern) 1981
Colombia 1980
Costa Rica 1981
Dominican Republic 1983
Ecuador 1979
El Salvador 1978
Guatemala 1983
Guyana 1975
Haiti 1983
Honduras 1981
Jamaica 1983
Mexico 1979
Panama 1979-80
Paraguay 1979
Peru 1981
Trinidad & Tobago 1977
Venezuela 1977
Percent who
Percent
do not want a who do not
birth during
want any
the next year more births
70*
76
8
31
65’
41’
77*
54*
33'
78
76
74"
86
86
27'
71*
84*
81'
90"
55
91
89
89
90
87
84
84
88
91
93
79
78
92
97
88*
90
84’
92'
Percent who use
Traditional Modern
method
method
Percent who know
Only
At least
traditional one modern
methods
method
11
4
35
14
14
4
7
18
22
19
10
2
4
3
7
3
1
4
1
1
12
1
19
1
6
1
10
3
0
1
0
4
28
27
1
6
9
66
1
5
2
12
21
1
2
13
80
28
61
18
83
61
6
20
59
50
89
53
42
41
36
67
19
1
5
5
5
7
0
23
21
22
15
35
1
0
0
0
1
0
0
90
100
92
78
98
24
48
51
42
76
43
42
42
58
65
66
4
6
4
11
10
0
1
21
25
3
9
36
24
43
26
7
4
17
32
56
0
0
1
0
2
0
0
0
0
0
96
100
79
100
92
52
75
95
100
100
52
74
58
49
69
53
72
59
53
40
62
59
76
54
65
63
31
74
56
57
2
15
8
14
8
9
4
8
2
4
3
3
3
3
6
5
13
25
6
12
45
11
29
52
43
57
43
27
32
21
32
4
24
49
34
57
25
18
49
38
0
6
0
0
0
0
0
1
0
0
0
0
0
0
0
0
1
6
0
1
99
51
99
100
96
100
99
90
99
83
95
86
93
100
90
99
95
78
99
98
Percent
knowing a
source for any
modern method
57
43
46
78
46
97
15
77
89
70
38
89
99
69
55
67
94
78
65
Percents not wanting a birth are adjusted to exclude the percent undecided or not stated. Traditional methods include douche, withdrawal, rhythm, abstinence, "other." Modern methods include
voluntary sterilization, oral contraceptives, intrauterine devices (IUDs), condoms, injectables, and vaginal methods (spermicides, diaphragms and caps). Women knowing at least one modern
method includes women who also know traditional methods.
only fecund married women are included
+ for married women aged 15-49, "use" statistics are for ever-married women, "source" statistic is for all women
# percents not wanting a birth are for 1978
Sources: "Fertility and Family Planning Surveys," Population Reports, series M, No. 8, Population Information Program, Johns Hopkins University, Baltimore, Md. September-October 1985. tables
3,6,7,9. "Kenya Contraceptive Prevalence Survey," Central Bureau of Statistics, Ministry of Planning and National Development, Nairobi, Kenya, 1984.
Demographic Data for Development Project
43
countries indicate that most women who want another
child do not want the birth within the next year. Most
women know that well-spaced children are healthier. In a
WHO study of 42,000 women in Latin America, North
Africa, and Asia, more than 90 percent of respondents said
that short birth intervals harm child health; in Zimbabwe
children bom too close together are said to “bum” each
other. Table 7-A shows the proportions of women who do
not want a birth during the next year, who want no more
births at all, and who know about and use contraception.
These patterns suggest that when contraception is empha
sized as a spacing tool, it may be more widely adopted.
One indicator of the unmet need for contraception is the
proportion of married women of reproductive age who
acknowledge not wanting a child in the immediate future
yet use no form of contraception. In most countries
surveyed, more than 75 percent of women did not want a
birth during the next year. Nonetheless, from a fourth to in
44
some areas nearly all of these women were using no con
traceptive method whatever, abstinence-based methods
included. By this indicator, the unmet need for contracep
tion is greatest in Africa, where in most countries surveyed
it exceeds 80 percent The level of unmet need also exceeds
80 percent in Bangladesh, Nepal and Haiti, and ranges from
24 to 71 percent in the rest of Asia and Latin America.
If a family’s goal is to have as many surviving children as
possible, high levels of fertility will be preferred, even
though their children’s survival chances are jeopardized.
A terrible price is paid for this means of achieving desired
family size. Yet it must be recognized that changes in goals
and philosophy are required if deaths from high-risk fer
tility are to be significantly reduced. Healthful spacing of
births and bearing children at healthful ages have such
tremendous positive effects on child survival that marshall
ing the political and social will necessary to initiate these
changes deserves the consideration of all.
Socioeconomic Factors and Child Survival
Education and Literacy
Availability of Modem Health Services
Income Per Capita and
Government Expenditures
Food Availability
Water Supply and Sanitation Facilities
45
EDUCATION AND LITERACY
PROFILE
The lowest mortality rates are found where large propor
tions of the population are literate and where educational
attainment is high. Because countries with high levels of
education are also more likely to provide such benefits as
clinics, hospitals, immunization programs, and clean water
systems, education is sometimes viewed as an indicator of
the presence of these other facilities. Education, however,
provides a major health benefit in and of itself. Mortality
levels are more closely related to national levels of literacy
than to levels and distribution of income. The global
association between female literacy and child mortality is
depicted in figure 8-A. Each point represents a country, and
shows that more children survive to age 5 in countries
where more women can read and write.
Within countries, a child’s risk of death is associated with
the education of his parents. The impact of parents’ educa
tional attainment on child survival is greatest in countries
where death rates are high. When education is com
monplace and mortality is low, everyone benefits from
decreased exposure to infectious diseases and the better
health and sanitation practices of neighbors. Educational
attainment also appears to be more important in areas
where government expenditures on health facilities are
low.
Figure 8-A
Pattern of Association Between Percent of Women Literate
and Percent of Children Dying Before Age 5
Represents one country
•
• Afghanistan
34
32
• Mali
• Sierra Leone
30
• Malawi
28
• Somalia
26
24
a>
o
a>
o>
20
o'
18
s
2
o
o
g
a>
• Yemen
22
• Swaziland
lesh
•
• Haiti
• Pakistan
• Zaire
16
• Egypt
14
• Peru *
• Morocco
.j^^wHonduras •
• Kenya^sk
•
12
Brazil
10
• Philippines
8
6
• China
• Malaysia
2
0
0
20
40
60
80
100
Percent of women 15 and older who are literate
Source: UNICEF and UNESCO. (Data are included in Tables 2 and 9 of Appendix 1.)
46
Demographic Data for Development Project
Figure 8-B
Figure 8-C
Mortality of Children From Age 1-5
of Mothers with No Education, and of Mothers
With at Least Primary School Education
Mortality of Children Age 1-4
According to the Educational Attainment
of their Mother or Father, Peru 1977-78
I
21 Mother's education
(
J Father's education
Mother has no education
24.1%
.......... Mother has at least primary school
21.7%
----23.7%
15.0%
Senegal
19-
Nepal
22.
Peru
O)
Q
S
-
■■I
<5
Q-
|
17.1%
■
■
|||b
I
■
5.5%
11.4
1.3
10.4
2.5
9.4
Bangladesh ;7___
9.2
2.0
8.6
Haiti
7.5%
19.4
Indonesia
5.2
Kenya
Pakistan
8.1
2A
8.0
7.7
Dominican Republic
None
1-3 years
4-6 years
7+ years
Educational Attainment
Source: Hobcraft, J., J.W. McDonald and S.O. Rutstein, "Socio-economic Factors in
Infant and Child Mortality: A Cross-National Comparison," Population Studies,
38(2): Table 6,1984.
Lesotho
7.5
6.5
Mexico ,8—
6.0
Colombia
Philippines
Demographic Data for Development Project
5.7
. .i
.4
4.7
Thailand .5
Panama .9
4.6
Costa Rica
Although a child is more likely to survive if both parents
are educated, his mother’s educational attainment appears
to be of greater benefit (figure 8-B). Studies indicate that for
every year of maternal education, infant and toddler
mortality is reduced by .6 percent, and for every year of
paternal education, mortality is reduced by an additional
.3 percent.
The importance of parental education to child survival
appears to increase from infancy to age 5. Data from World
Fertility Surveys on mortality among infants and children
of varying socioeconomic status in 28 developing countries
found the highest infant death rates to be approximately
double the lowest rates. By contrast, the highest death rates
of older children were often four times higher than the
lowest rates. From birth to age 5, parental education
emerges as more important to survival than father’s
occupation, mother’s work status, or mother’s urban or
rural residence. Figure 8-C shows the difference in mortali
ty of children age 1 through 4 of uneducated and primary
school educated mothers.
Further, studies have shown that children of educated
and literate parents exhibit consistently better levels of
nutrition than do children of less educated and illiterate
parents. This is true even when income levels are the same.
3.7
4.5
Korea
Paraguay
.8
4,2
Jordan
Sri Lanka
Syria 14^i?
Venezuela
Jamaica
1.3_2.5
Guyana
Malaysia LJ9
Trinidad & Tobago
■7-11
0
5
10
15
20
Percent of 1-Year-Olds Who Die Before Age 5
Source: Hobcraft, J., J.W. McDonald and S.O. Rutstein, "Socio-economic Factors in
Infant and Child Mortality: A Cross-National Comparison," Population Studies,
38(2): Table 6,1984.
Demographic Data for Development Project
47
IMPACT ON CHILD SURVIVAL
Education can help persons mobilize resources for a
healthier community and maximize their effective use.
Schooling imparts useful skills and knowledge, and
establishes new attitudes.
Literacy: Parents who can read and write have greater
access to information. A literate mother who can read the
instructions on a packet of oral rehydration salts is more
likely to administer them correctly. She can better unders
tand posters that offer child-care advice. The ability to write
enables her to record her children’s vaccinations, and to
monitor their growth in height and weight.
Skills in using institutions: Women who have attended
school have had experience with an institution beyond the
family, and may be more likely to approach, and have skills
in using, clinics and other medical institutions. They may
be less shy and more articulate in asking questions of
health professionals. These women may also be more likely
to perceive such services as a right, and to insist that their
children be given attention.
Grasping new ideas: Education improves the ability to
deal with new ideas, and to accept concepts that appear
contrary to common sense. The process of taking a child
to a stranger, who, by sticking a needle in him, makes him
howl and break out in a fever is difficult to perceive as a
health benefit. A child suffering from diarrhea appears to
have an excess of water, not to need more. Education is the
bridge to understanding that vaccination and oral rehydra
tion are lifesaving procedures that must be undertaken if
a child is to survive.
Learning self-reliance: Educated parents are less likely
to be fatalistic about their children’s health—to instead take
more active, personal responsibility for their care. School
ing may also lessen reliance on the opinions of elders, giv
ing educated family members the freedom to follow a more
independent course in efforts to improve their well-being.
Changing perspectives on health: Schooling can
change mothers’ perspectives on child care and health by
encouraging the provision of resources to their children.
Although education generally improves attitudes toward
health, it can sometimes have negative effects, as when
breastfeeding, by being presented as old-fashioned, is
discouraged.
Greater productivity: Educated parents tend to be better
off economically. When they earn higher wages, they can
buy more and better food, and obtain better medical care.
Educated parents may also be more productive at home,
e.g., in effectively preparing and storing food.
48
Figure 8-D
Percent of Adult Women Who Ever
Attended School, Distributed by Highest
Level Ever Attended, Kenya 1979
j 2] Attended College
| Attended Secondary
|
| Attended Primary
1.1
o
o
18.3
I
■O
a>
o
a>
.9
7.7
41.0
38.1
.5
1.7
o
22.2
5
5
13.7
a>
a.
20-24
25-34
35-44
45-54
55 +
Age in 1979
Source: United Nations Demographic Yearbook 1983, Tables 26 and 38,
United Nations, New York, N Y. 1985.
Demographic Data for Development Project
THE ROAD TO HEALTH
Health and education have many characteristics in com
mon: as human capital investments embodied by
individuals, both are valuable in the long run; both are the
joint outcome of public efforts and individual decisions;
and both, in addition to being of intrinsic value, act to in
crease economic activity and earnings.
Education is a critical element in improving child sur
vival. Educated parents are more skilled in child care, and
better able to mobilize limited resources to improve health.
Moreover, each additional year of parental education, par
ticularly maternal education, is beneficial to the survival of
a family’s children, and this education increases in impor
tance to the child between birth and age 5.
Unfortunately, the benefits of maternal education have
had little impact because until recently few women were
able to attend school. The educational attainment of
younger women will be significantly higher, based on cur-
Figure 8-E
Percent of Men and Women Who Can Read and Write
Literate
Illiterate
68%
57%
Men
35%
61%
38%
44%
Women
Near East
Africa
82%
84%
55%
80%
China
Asia'
Latin America
& Caribbean
* Excluding China
Demographic Data for Development Project
Source: UNESCO (Data are included in Table 9 of Appendix 1.)
Figure 8-F
Percent of Boys and Girls Who Attended Primary School in 1960 and 1980-84
o
Boys
Girls
100%
97%
100%
100%
91%
100%
93%
77%
78%
87%
73%
85%
50%
60%
1960
1980-84
Africa
1960
1980-84
Near East
1960
1980-84
Asia*
1983
China
1960
1980-84
Latin America
& Caribbean
‘Excluding China
Gross enrollment ratio exceeds 100 percent when persons of other age groups are attending school; percents for boys in 1980-84 in the Near East and China, and for boys and
girls in 1980-84 in Latin America & Caribbean are truncated to 100 percent.
Source: UNESCO (Data are included in Table 9 of Appendix 1.)
Demographic Data for Development Project
Note:
49
rent levels of enrollment. An example of progress in the
enrollment of women is shown for Kenya in figure 8-D.
Only about one-third of women are literate in all develop
ing regions except Latin America and the Caribbean. Pro
portions of literate men and women are shown in figure
8-E. Though enrollment has increased for girls, it still lags
behind enrollment of boys. Differing educational oppor
tunities for boys and girls and the progress made in this area
over the past 2 decades are shown in figure 8-F. Primary
enrollment is approaching 100 percent for boys in all
regions except Africa; girls are almost 100 percent enrolled
in China, Latin America, and the Caribbean.
Fewer than half of children who go to primary school go
on to secondary school. The gap between male and female
enrollment in secondary school is even wider. Only 11 per-
50
:::
cent of African, 35 percent of Near Eastern, 28 percent of
Asian, and 51 percent of Latin American/Caribbean girls
are enrolled in secondary school.
The need for increased education is clear, as is the need
for a major commitment to prioritize education for women.
Although progress is being made, further strides are needed
to reach 100 percent enrollment of boys and girls. Because
female education is such an important benefit to children,
the argument can be made that education of girls should be
given greater emphasis. Secondary education, which fur
ther broadens the base of understanding about disease and
health, becomes an essential goal once high levels of
primary education are achieved. In areas where a large pro
portion of adult women have never gone to school, adult
literacy programs offer an important alternative.
IX. AVAILABILITY OF MODERN HEALTH SERVICES
PROFILE
Figure 9-A
The development of relatively simple, effective, and inex
pensive health technologies has opened the doors for the
child survival revolution to spread to all parts of the world.
High rates of childhood mortality and morbidity none
theless persist. A large gap remains between what can be
done given current resources and knowledge and what has
actually been achieved. The impediment to child survival
in this case is not disease or malnutrition, but a lack of
available health services to address local health needs. The
challenge is to design, implement, and manage appropriate
systems that ensure that these critical technologies can be
put to work when and where they are needed.
Health Expenditures and Population Served:
Expenditures for Primary Health Care and
Hospital Care in Ghana
Hospital care receives
85 percent of national
health expenditures...
.. .and serves
10 percent
of population
IMPACT ON CHILD SURVIVAL
The clinical effectiveness of the major child health
technologies has been proven. For every disease prevented,
every birth spaced, every illness or injury treated, a life may
be saved. But the impact of these health services at the na
tional level varies considerably. The ultimate outcome of
efforts to improve health is subject to the economic, social,
and political forces that affect the distribution of critical
health services and how they are used. The level of
economic development clearly has an important influence
on the resources that can be devoted to health care. But
when economic resources are limited, the impact of health
services depends on their ability to reach the areas of
greatest need and to address the basic health needs of the
broad population. The availability, accessibility, and
appropriateness of health services are closely related to one
another, and are important determinants of child survival.
Availability
The simple presence of health facilities, supplies, and per
sonnel in a country does not in itself guarantee a strong
positive impact on child survival. With few exceptions,
health systems in developing countries have been modeled
after those in industrialized nations, which emphasize
curative care in sophisticated hospital settings. The cost of
maintaining the facilities, equipment, supplies, and highly
trained personnel needed to run such institutions tends to
quickly absorb most of the national resources devoted to
health (see figure 9-A). The World Bank has estimated that
on average two-thirds of government health expenditures
in developing countries go to teaching hospitals and
medical training. Investments in advanced medical care
typically come at the expense of simpler preventive and
promotive services that have the potential to make a much
Primary health care
receives 15 percent of
national health
expenditures...
.. .and serves
90 percent
of population
Source: Adapted from UNICEF, The State of the World's Children 1985, Oxford
University Press, New York, 1985. Figure 20 from "A Primary Health Care
Strategy for Ghana,” April 1978, Ministry of Health, Accra, Ghana.
Demographic Data for Development Project
greater impact on health. As a result, while some health ser
vices are technically “available” in these countries, health
care is effectively nonexistent for those who cannot reach
the hospitals or afford their services.
Accessibility
The accessibility and appropriateness of health services are
closely related factors that can have a decisive influence on
health care. Accessibility is a critical factor that has different
meanings in different settings. It is not only measured in
terms of distance, but also in terms of affordability of ser
vices and the absence of social and cultural barriers to their
use. Figure 9-B depicts a model of health center utilization
in a rural developing country location. In areas where
transportation is poor, the use of health facilities drops off
sharply beyond a 3 to 5 kilometer (2 to 3 mile) distance. In
another context, people may be discouraged from using
local health services because they are too expensive, too in
convenient, or too intimidating. The design of^acixs^hje”
services must take all of these potential factors into con
sideration in each new area.
The private sector is playing an increasingly important
role in improving access to health services in developing
countries. Consistent with the primary health care ap
proach, the provision of supplies and services through
commercial channels can expand the reach of simple but
powerful health technologies such as ORT, immunization,
and contraceptive methods beyond the clinic and hospital
setting. The idea is not new. Chloroquine treatment for
malaria, for example, has been commercially available
throughout endemic regions for many years. More recendy,
social marketing to advertise and sell ORT packets and
contraceptive methods at reduced cost is proving effective
in a number of developing countries. These programs are
designed to reach people who, for whatever reason, cannot
or choose not to use clinic services. Through the private
sector, simple health technologies could become available
as dependably as, for example, soft drinks are today, even
in the most remote locations. Distribution of supplies and
services on this scale would be a major step toward achiev
ing the goals of the child survival revolution.
Figure 9-B
Utilization of Health Services According
to Travel Distance: A Theoretical Model
81%
Percent of ill
individuals using
health center by
distance from dwelling
49%
25%
■9%\
Health Center e
is
Appropriateness
Appropriate health care might be defined as the kind of
health care, within available resources, that most effectively
addresses the prevailing health conditions of a population.
What is or is not appropriate health care is best determined
based on local health conditions and the resources that can
be allocated. Considerations include choice and distribu
tion of services offered, type of personnel and training
necessary, and the balance of preventive and curative ser
vices. The overwhelming emphasis on curative measures
that often comes with the Western model of health care is
questionable in areas where so many die from preventable
causes. The approach is both more expensive, requiring
highly trained personnel, costly equipment, and relative
ly elaborate facilities, and tends to limit the range of
available services to those areas that can support the
logistical and financial requirements of such institutions.
In developing countries, this almost invariably means ur
ban areas. While urban populations and their health needs
are growing rapidly, most of the world’s people and the
worst health conditions are still found outside the cities.
Use of Services
The crucial link between providing health services and im
proving health is public acceptance and motivation to use
the services provided. Demand for services is often taken
for granted where health conditions are poor, but cannot
be assumed. Modem health treatments such as immuniza
tion or ORT may compete with traditional health practices,
or with fatalistic views of disease that discourage parents or
52
Source: Reinke, W.A., Mathematical Models of Basic Health Care, 1979
Demographic Data for Development Project
other caregivers from taking action. Before people will
adopt effective measures for child survival, they must first
be made aware that alternative treatments exist, and that
they are, in fact, better. Secondly, they must be willing to in
vest their time and effort in the process, and to entrust their
children’s lives to unfamiliar practices and practitioners, no
small demand in itself.
Both public and private sectors have important roles to
play in increasing awareness and use of existing health ser
vices. As has been noted, social marketing techniques can
enhance the role of the private sector in expanding the
reach of simple health technologies beyond clinic settings.
These techniques can also help to increase awareness of
these life-saving measures and bridge the gap between the
availability of health services and their use.
A community’s willingness to take advantage of health
services depends to a great extent on the social and cultural
context into which they are introduced. Since mothers are
the primary child care providers in virtually all cultures,
their attitudes and practices are likely to be a critical factor
in the optimal use of health services for children. It is not
surprising, then, that the level of female literacy is a key fac
tor not only in the adoption of modem health care but in
child survival in general.
The experience of Kerala State in India provides a good
example of what can be achieved when the three issues of
availability, accessibility, and appropriateness of health care
are effectively addressed through the public sector. The
state has achieved high health standards despite its ex
tremely low level of economic development. Within India,
it is paradoxically the poorest state in terms of per capita in
come levels, and the most advanced in terms of life expec
tancy and infant survival. One of Kerala’s distinguishing
features is its political commitment to provide basic health
services to all, including the poorest and traditionally most
underserved portion of the population. As a result, a
minimum level of health care that includes both preven
tive and curative services has been made widely accessible.
Perhaps most remarkable is Kerala’s high utilization rate of
these services. In terms of outpatient visits to clinics and
babies bom in health facilities; Kerala stands well above
neighboring states with comparable health systems. This
achievement appears to be linked to the traditionally high
literacy rates in Kerala, especially among women. They are
not only more open to the notion of modem health care for
their children, they demand it. The state’s high standards
for equitable health care are believed to be a tangible reflec
tion of this demand.
Kerala’s example also points out that improvements in
health are rarely isolated—that they are likely to be accom
panied by other aspects of development. In the case of
Kerala, social rather than economic development has made
the difference. Education has played a major role, as has the
government’s commitment to secure health as a goal in its
own right.
Primary health care is particularly well-suited to solving
the problems of availability, accessibility, and
appropriateness in developing countries. It entails a com
prehensive approach to health that is designed to shift the
traditional emphasis from a few specialized institutions to
the areas of greatest need — the local communities. The
concept is simple: a country’s greatest resource for health
is the potential for its people to take care of themselves. A
health system that is community-based can combine
education and community participation with the provision
of essential health services. When health services are
weighed in the local context, efforts to make them ap
propriate for local needs and accessible to everyone
become an integral part of the planning process.
The success of community based health services
ultimately rests on the approval and active participation of
the local community. Primary health care includes ac
tivities in each of the major categories—preventive,
curative, promotive, and rehabilitative. They are limited
only by what is economically and culturally feasible on the
local level. Although the design of services for each com
munity will vary according to local health needs, a list of
essential services provides a common framework for a
primary health care system:
• education concerning prevailing health problems and
the methods of preventing and controlling them;
• promotion of food supply and proper nutrition;
• maternal and child health care, including family
planning;
• immunization against the major infectious diseases;
THE ROAD TO HEALTH
• prevention and control of locally endemic diseases;
• appropriate treatment of common diseases and injuries;
Primary Health Care
The primary health care approach provides a solid foun
dation for addressing the health needs of developing areas
by using the means at hand. It is at the heart of current ef
forts to make better use of today’s limited health resources,
and has been adopted and endorsed by all of the major in
ternational organizations concerned with health, including
the World Health Organization, UNICEF, and the United
States Agency for International Development. Primary
health care is the basis of an international drive to improve
health for all by the year 2000, with special emphasis on
reducing the toll of illness and death among children.
• provision of essential drugs; and
• basic sanitation and an adequate supply of safe water.
One of the most important aspects of the primary health
care approach is that it recognizes that improvements in
health are an integral part of development, not simply a
byproduct of it. This has been confirmed in Costa Rica, Sri
Lanka, China, and India’s Kerala State. In each country, suc
cess meant reaching out to provide health services to those
most often excluded. And in each country, children have
been found to benefit the most when health conditions
improve.
53
X. INCOME PER CAPITA
AND GOVERNMENT EXPENDITURES
PROFILE
through more plentiful and nutritious food, improved
housing, water and sanitation systems, and expanded
education and medical facilities.
Yet although health improvements appear to accompany
economic development, experience has shown that this is
not necessarily the case, and in many developing countries,
most notably those in SubSaharan Africa, economic
development has proceeded slowly, if at all. Moreover, the
experience of most developing countries shows that the
benefits of economic development are unevenly distrib
uted among the population. Typically, urban areas that
The generally positive relationship between economic
development and health status is reflected in a country’s
levels of per capita gross national product (GNP) and life
expectancy. Life expectancy in high-income countries such
as Sweden and the United States is 30 to 40 years greater
than in low-income countries such as Ethiopia and
Bangladesh (see figure 10-A), where infant and child mor
tality persists at high levels. Health gains in developed
countries have been achieved and sustained in association
with increased economic development, specifically
Pattern of Association Between Gross National Product Per Capita and
Life Expectancy (using a log scale for GNP)
•
Represents one country
80
75
•
• Costa Rica
• Venezi
Sri Lanka
70
• El Salvador
• Saudi Arabia
• Malaysia
•Mexicj
65
• Guate^affla
• Libya
•Tunisia
o
>»
60
• Gabon
• India
o
o
q>
• Cameroon
55
• Oman
a>
50
• Congo
•Banglai
45
• •Senegal
• Ethiopia
40
• Sierra Leone
35
100
500
1,000
3,000
7,500
20,000
Gross national product per capita, 1983 US dollars
Source: United Nations Population Division and World Bank Atlas (Data are included in Tables 5 and 10 of Appendix 1.)
54
Demographic Data for Development Project
f
become pockets of intense industrial or commercial activi
ty reap the greatest benefits, while rural areas remain
neglected. This is particularly true of the distribution of
health care services in much of the developing world. Thus,
while a country’s per capita income level may be increas
ing, large segments of its population may experience no im
provement in their standard of living. This has alarming
implications for infant and child health in areas where most
individuals have no access to essential life-promoting
amenities. This pattern can be seen, for example, in several
high-income countries in the Near East, which continue to
show high mortality rates despite their aggregate wealth.
Increases in GNP also do not necessarily translate into in
creased government expenditures in the health sector; they
may in fact have the opposite effect. In many developing
countries, spending on defense has increased dramatically
in recent years, while expenditures on health have re
mained constant or declined. As shown in figure 10-B, the
average developing country government devotes less than
6 percent of its expenditures to health; levels of spending
on defense, education, and housing, social services and
welfare respectively are twice this amount. Correcting this
imbalance may require redefinition of security issues and
recognition by national leaders of the long-term economic
and social benefits of increased health expenditures.
It is also important to note that significant improvements
in health are possible without high levels of economic
development. Even in the poorest countries, there is com
monly a small segment of the population that enjoys high
life expectancy and high health standards. Several societies,
notably Sri Lanka, China, and Kerala State in India, have
added 15 to 20 years to life expectancy at annual per capita
income levels of around $300. In the Latin American
region, Costa Rica has attained mortality rates that ap
proach those of developed countries, at a small fraction of
their GNP levels. A number of factors have contributed to
these accomplishments, but each success has been marked
by political and popular commitments to health and
education for all, emphasis on adequate nutrition and
health care for even the most under-privileged, and a com
mitment to the ideal of popular participation in public
affairs.
Finally, health and development will continue to proceed
hand in hand. Poverty and poor health powerfully rein
force each other. Hence improvements in health are an im
portant contributor to economic development, not simply
Figure 10-B
Percent of Government Expenditures
Developing Countries Spend on Health,
Education, Housing, Social Services and
Welfare, and Defense
a
14.9
Q.
13.3
<5
E
c
o
5.5
o
o>
o_
Health
Education
Housing,
Defense
Social Services,
and Welfare
Note: Values are unweighted averages of countries with data available.
Source: World Bank, World Bank Development Report. Table 26, Washington, D.C., 1985.
Demographic Data for Development Project
a passive result of it In other words, an investment in health
is an investment in development as well.
THE ROAD TO HEALTH
Economic development can be an important factor in
securing better health for children. But it is neither a re
quisite nor a guarantee of health gains. The extent to which
economic development improves child survival depends
on the extent to which it improves the standard of living
and health conditions for the most disadvantaged segments
of the population. Sustained political commitment to
equitable distribution of services among the population
and increased public expenditures on health and related
sectors can translate increases in per capita GNP into
improvements in child survival.
55
XI. FOOD AVAILABILITY
PROFILE
From a child’s perspective, hunger is a simple fact. It means
not having enough to eat, and is the same for hungry
children no matter where they live. Yet a shortage of food
on the national or community level may not be the domi
nant factor when malnutrition strikes. Indeed, hunger and
malnutrition occur in areas where the overall food supply
is abundant. The accessibility of food and the equity of its
distribution among a population are important determi
nants of health conditions in countries throughout the
world.
IMPACT ON CHILD SURVIVAL
On an individual level, malnutrition results from the com
bined effects of disease and inadequate diet. The latter can
occur as a consequence of arbitrary feeding practices as
well as from deficient resources. Hence the problem of
child malnutrition in the world today cannot be addressed
without recognizing the potential for improvement within
current food resources through simple health and educa
tion measures.
Nonetheless, the overall food supply remains the
ultimate limiting factor in the malnutrition equation. Below
a certain level, all the health interventions in the world can
not spare a child from malnutrition and poor health. Im
provements in the general level of nutrition in western
Europe and the United States are credited with bringing
about significant declines in mortality during the 19th cen
tury, well before the advent of modem medical technol
ogies. These improvements were the result of increased
production of food and better diets, but of equal impor
tance were the relative decline in food prices that made
food more accessible, and better transportation and storage
facilities that dampened the effects of localized crop failures
and sporadic food shortages.
Children are always at highest risk of malnutrition
because of the extra demands placed on them by physical
growth and frequent infection. As a result, fluctuations in
Percent of Children Dying Before Age 1 and Per Capita Calorie Availability: Sri Lanka, 1950-80
Total calories per day
Percent dying
2400
;>6
2300
o
o'
5
a>
o
o
o
2
‘o.
5
2200
o
2100
®
a>
a.
2000
3
1955
1960
1970
1965
1975
1980
Year
Source: Fernando, D„ 1985 "Health Statistics in Sri Lanka 1921-80 in Good Health at Low Cost, S. Halstead, J. Walsh and K. Warren (eds.). The Rockefeller Foundation:
New York, 1985.
56
io
o
,
Demographic Data for Development Project
4
a
Map 11-A
1982-84 Per Capita Food Production as a Percent of 1969-71 Production
Less than 80
80 to 90
90 to 100
No Data
Source: World Bank (Data are included in Table 8 of Appendix 1.)
oj
Demographic Data for Development Project
the overall food supply are reflected in the level of child
mortality. The pattern of food availability and infant mor
tality in Sri Lanka, as shown in figure 11-A, suggests a direct
relationship. Each increase in total caloric energy supply
per capita is followed by a decrease in the infant mortali
ty rate, often with a 1-year lag time. When energy availabili
ty decreased, in most cases the infant mortality rate ex
perienced an increase over a 1- to 2-year period.
for widely in levels of development, types of economic
system, and forms of government. But their success at im
proving health within developing economy constraints
contains common elements that can be applied elsewhere.
These five basic elements are:
Global Food Supply
• widespread participation in the political process,
During the last two decades, food availability has increased
for the world as a whole, despite rapid population growth
and short-term fluctuations caused by famine and war. The
trend can be seen in map 11-A, in which the average index
of food production for 1982-84 is expressed as a percent of
per capita food production around 1970. The most
remarkable advances have been achieved in South East
Asia, once the focus of global malnutrition. India, which
suffered periodic famines well into this century, is now a
net food exporter. Although malnutrition still exists in
many areas of Asia, the trend is toward increasing food selfsufficiency and better nutrition for the broad population.
Many countries in the Near East and Latin America and the
Caribbean have also enjoyed net gains in available food
calories per capita by comparison to 10 or 20 years ago. The
major exception to these positive regional trends is Africa.
For all but a handful of countries in SubSaharan Africa, the
rate of food production has not kept pace with population
growth. Many factors have contributed to this stagnation,
including political instability, the worldwide economic
recessions of the 1970s and 1980s, some of the highest
population growth rates ever observed, and, most recendy,
the catastrophic drought that has affected much of SubSaharan Africa. As a result, there is less available food per
capita in Africa as a whole today than there was 20 years
ago.
• equality of health services coverage for all social groups,
and
THE ROAD TO HEALTH
On the one hand, resolution of the problem of malnutri
tion in the developing world is linked to long-term growth
in the availability of food, as it was in the history of western
industrialized countries. Yet on the other hand, the experi
ence of several countries in the developing world has
shown that malnutrition can be greatly reduced even
within present constraints on total food supply and
economic development In their recent study “Good Health
at Low Cost,” the Rockefeller Foundation details the model
efforts of selected developing countries to reduce mortality
and improve health. The subject areas are China, Sri Lanka,
Costa Rica, and Kerala State in India. All four have achieved
rates of mortality and life expectancy that approach
developed country levels while remaining within develop
ing country levels of GNR The countries represented dif-
58
• strong commitment to health as a social goal,
• social welfare orientation to development,
• linking health programs with general economic
development.
In all four areas, efforts to raise general nutritional stan
dards were only one part of a broad campaign to improve
living conditions through education, health, and various
other development initiatives. Each program directly or indirecdy contributed to the success of the others. Together
they made a significant impact on health conditions where
singly they might have failed.
Making basic food supplies accessible to those in need
and distributing them equitably have been key elements of
nutrition programs in all four of the examples. Each area
has developed its own approach toward achieving these
goals. China has utilized its planned economy to institute
a two-pronged strategy to promote food self-sufficiency
among production groups while providing safeguards for
periods during which food production falls short. Kerala
and Sri Lanka have traditionally relied on subsidies and
rationing plans that provide up to 20 percent of total calorie
intake for low-income households. The system has been
effective in reaching low-income families who might other
wise be hard-pressed to feed themselves. Costa Rica has
taken yet another approach, using the primary health care
system to target groups at high risk of malnutrition and pro
vide them with supplemental foods. This effort includes
school lunch programs, supplements for pregnant women
and children threatened with malnutrition, and general
food assistance programs.
Finally, all four have demonstrated the political will to
support health and nutrition initiatives despite their cost.
These programs represent a substantial investment: before
Sri Lanka was hit by an economic crisis and forced to cut
back, the rationing coupon system for rice and other essen
tial foods accounted for up to 24 percent of its total govern
ment budget. Kerala State invested 17 percent of its state
budget on its subsidy and rationing plan. The investment
and effort required to plan, implement, and manage the
programs was in all cases substantial. But in terms of
absolute dollars, the gains in health and nutrition were
achieved at relatively modest cost.
<
WATER SUPPLY AND SANITATION FACILITIES
PROFILE
of urban and rural populations to safe water and sanitation
facilities is shown in figure 12-A. In recognition of the dire
status of water supplies and sanitation facilities in the
developing world, the United Nations declared 1981-1990
as the International Water Supply and Sanitation Decade.
This decade is dedicated to speeding the construction of
new water supply and excreta disposal facilities, and to
maximizing the probability that they will be correctly
operated, maintained, and used. At mid-decade the goal of
universal access by 1990 remains distant.
Clean water is a critical factor in maintaining good health
and preventing illness. A “safe” water supply includes
treated surface waters or untreated but uncontaminated
water such as that from protected boreholes, springs, and
sanitary wells. Reasonable access in an urban area is pro
vided by a public fountain or stand post located not more
than 200 meters from a residence. In rural areas access is
deemed reasonable when members of a household do not
have to devote a disproportionate part of the day to fetching
the family’s water Though daily water requirements vary by
body weight, health status, clothing, activity, and climate,
the average adult male needs a daily minimum of 2 to 2.5
liters for drinking, and an additional 20 to 40 liters for per
sonal and domestic hygiene.
Today, only half of the population of developing coun
tries (excluding China) has access to safe water, and only
a third has access to sanitation facilities. Among regions,
Africa has the smallest portion of the population served.
Within countries, the worst conditions are found in rural
areas, even though in these areas the availability of space
and materials may make the construction of sanitation
facilities (e.g., pit latrines) relatively simple. Regional access
WATER
Water Quality: Water affects health in four major ways.
First, water can carry pathogens which, when ingested in
sufficient quantity, can infect the drinker and cause micro
biological diseases (e.g., cholera and typhoid). Water may
also carry toxic substances such as industrial wastes.
Second, water is important for cleanliness, especially for
flushing away feces and urine. Hand-washing is an impor
tant personal health measure. Washing, domestically and
in personal hygiene, reduces the incidence of diarrheal
diseases, skin diseases such as yaws, eye diseases such as
trachoma (a leading cause of preventable blindness), and
Figure 12-A
Percent of Population with Access to Safe Water and Sanitation Facilities
Safe Water
Sanitation Facilities
With access
With access
Without access
Without access
16
65
84
67
87
Urban
16
44
Rural
Africa
Near East
Asia-
Latin America
& Caribbean
Africa
Near East
Asia’
Latin America
& Caribbean
’Excludes China
Note: Regional estimates are averages for countries with data available. Regional estimates in the U N. source document differ slightly,slightly; Asia, percent with urban sanitation
facilities is 48%.
Source: United Nations, General Assembly, Economic and Social Council (Data are included in Table 10 of Appendix 1).
Demographic Data for Development Project
59
ectoparasitic diseases such as louse-bome typhus.
Third, water can be a critical link for diseases that depend
on transmission by animals or insects that spend some or
all of their lives in water. Malaria, which is transmitted by
mosquitoes, is a prominent example.
Fourth, farming, and the process of collecting water from
streams and lakes, may expose persons to diseases through
skin penetration. An example is schistosomiasis, caused by
parasitic worms.
Diarrheal diseases are often a consequence of unclean
water. For a single pathogen, the higher the ingested dose,
the greater the risk of severe diarrhea and death. Studies of
water supply and excreta disposal improvement projects
often reveal greater declines in incidence of severe diarrhea
and mortality than in incidence of mild diarrhea, which in
some cases does not decline significantly. Improvement in
nutritional anthropometric status—height and weight—is
also seen when water quality and waste disposal are im
proved. The median reduction in diarrheal morbidity
obtained from 44 studies of water and sanitation improve
ment is shown in table 12-A.
Water Availability: Where families lack a running tap in
the house and water must be drawn and stored for use, the
risk of pollution rises because containers may be con
taminated and because water is allowed to stagnate,
generally without refrigeration. When infant formula
nutrients are added to water collected in this manner; path
ogens flourish. Households that lack safe water experience
greater infant and child mortality when children are not
breastfed.
When washing of hands and utensils, which reduces
contamination by fecal matter, depends on water that must
be drawn and stored, frequent, abundant use is necessarily
limited and risk of infection rises.
Women and children are particularly affected by the
availability of water because it is usually the woman’s task
to fetch water. The greater the distance to water, often a
matter of miles requiring hours of walking each day, the
less time a woman has for child care and other domestic
chores, and the more calories she must expend. A woman
who travels over hilly terrain may use from 15 to 27 per
cent of her caloric intake in fetching water. In urban areas,
water often needs to be purchased, which places a heavy
burden on meager household incomes.
SANITATION FACILITIES
Because so many of the major infectious agents of disease
are shed by infected persons via feces and urine, hygienic
disposal of waste is vitally important. Use of toilets can
reduce fecal contamination of houses, yards, and neighbor-
60
Table 12-A
Reduction in Diarrheal Morbidity Rates
Attributed to Improvements in
Water Supply or Excreta Disposal
Median percent
reduction
Water quality
improvement
16
Water availability
improvement
25
Water quality and
availability improvement
37
Excreta disposal
improvement
22
Source: Esrey, S.A., R.G. Feochom and J.M. Hughes, Interventions for the Control of
Diarrheal Diseases among Young Children: Improving Water Supplies and
Excreta Disposal Facilities, WHO Bulletin 63(4), Table 2,1985.
Demographic Data for Development Project
hoods. It can also reduce contamination of crops and
drinking water supplies. Hygienic disposal of feces of
children who are too young to use a toilet is of particular
importance.
THE ROAD TO HEALTH
Greater access to inexpensive, abundant, and clean water
and to effective sanitation facilities is a pressing need in
developing nations. The lack of these systems exacts a
heavy toll on health, as well as on time and money.
Creative alternatives to current methods of providing water
are needed to overcome the often prohibitive costs and
problems of conventional construction and maintenance.
Encouragement is needed to identify and use uncon
taminated sources (e.g., wells from protected aquifers), treat
raw surface water (e.g., with chlorination), protect water
sheds, and increase water quality surveillance. Excreta
destruction and removal, or at least isolation from water
supplies, is needed.
Education in the correct utilization of water and sanita
tion facilities should be an integral part of providing facili
ties. When the mother of a family is literate, she is more
likely to understand the reasons for adopting improve
ments in excreta disposal, and to take the actions necessary
to limit disease transmission from this source. Understand
ing of the link between disease and water, and the impor
tance of washing and using toilets, cannot be taken for
granted, even in the developed world.
Summary Chart
Child Survival Summary Chart
MAJOR IMPEDIMENTS TO CHILD SURVIVAL
SELECTED INGREDIENTS OF THE ROAD TO HEALTH
DIARRHEAL DISEASE
• Oral Rehydration Therapy (ORT):
— Administration of oral rehydration solution
— Continued feeding
— Referral when appropriate
• Breastfeeding
• Hygienic practices in household (e.g., hand washing, hygienic
handling and storage of food and water)
• Improved water and sanitation supplies
• Immunization
VACCINE-PREVENTABLE DISEASES
Diphtheria, Measles, Pertussis (Whooping Cough), Polio,
Tuberculosis
Tetanus
Neonatal Tetanus
• Immunization by age 1
• Adequate nutrition
• Less crowded living conditions
• Immunization by age 1
• Hygienic treatment of wounds and injuries
• Immunization of women of childbearing age
• Hygienic conditions and practices at birth (especially sterile ■
treatment of umbilical cord)
• Assistance at birth by trained birth attendants
ACUTE RESPIRATORY INFECTION
• Immunization for vaccine-preventable diseases
• Curative drug therapy
• Adequate nutrition
• Improved housing conditions (e.g., less crowding)
• Health education for parents and other caregivers to recognize and
seek treatment for severe respiratory infection
• Expanded availability of services for the treatment of acute
respiratory infections
MALARIA
• Environmental control of mosquito vector (e.g., limiting breeding sites)
• Chemical control of mosquito vector (e.g., spraying with
insecticides)
• Limiting malaria transmission through preventive action (e.g., use
of screens and bed nets)
• Anti-malarial drugs
• Possible vaccine in next decade
• Education on the patterns and prevention of malaria
MALNUTRITION
• Improved maternal health and nutrition during pregnancy
• Breastfeeding
• Improved weaning practices (e.g., timely initiation, adequate
duration, and maintenance of a balanced diet through weaning)
• Improved child feeding practices (e.g., meeting the protein, energy,
and micronutrient needs of a growing child)
• Feeding during illness
• Growth monitoring
HIGH-RISK FERTILITY
• Lengthening birth intervals
• Shifting childbearing away from very young and very old repro
ductive ages
• Avoiding very high parity
• Breastfeeding
• Provision of family planning services:
— Wide and reliable distribution of contraceptive methods
— Information and education on use and benefits of family planning
62
SOaOECONOMIC FACTORS AND CHILD SURVIVAL
SELECTED INGREDIENTS OF THE ROAD TO HEALTH
EDUCATION AND LITERACY
• Priority on primary and literacy education, especially for girls
• Increase percentage of girls receiving secondary education
• Literacy programs for nonliterate adult women
AVAILABILITY OF MODERN HEALTH SERVICES
• Provision of health services that are reliably available, accessible to
all, and appropriate for local health conditions
• Balance between preventive and curative services
• Emphasis on the primary health care approach. The main tenets of
this approach are:
— Education concerning prevailing health problems and the
methods of preventing and controlling them
— Promotion of food supply and proper nutrition
— Maternal and child health care, including family planning
— Immunization against the major infectious diseases
— Prevention and control of locally endemic diseases
— Appropriate treatment of common diseases and injuries
— Provision of essential drugs
— An adequate supply of safe water and basic sanitation
INCOME PER CAPITA
AND GOVERNMENT EXPENDITURES
• Long-term development with the equitable distribution of
economic resources
• Reduction of financial barriers to access to health care
• Commitment to wide participation in the provision and use of
health services
FOOD AVAILABILITY
• Efficient distribution and use of existing food resources
• Long-term growth in food availability
• Distribution of food supplies to those in greatest need (e.g., supple
ments for mothers and children in high-risk groups, food rationing,
food subsidy programs)
WATER SUPPLY AND SANITATION FACILITIES
• Education in use of sanitation facilities
• Education in importance of safe water
• Reduction of time and money required to obtain water
• Reduction of the need for home storage of water
• Promotion of washing for personal and domestic hygiene
• Efficient management of existing water resources:
— Identification and use of uncontaminated sources
— Treatment of raw surface water
— Protection of watersheds
— Increased water quality surveillance
— Destruction/removal of excreta
— Isolation of excreta from water supplies
63
Selected Bibliography
65
Selected Bibliography: Diarrheal Disease
Black, R.E., et al., “Handwashing to Prevent Diarrhea in Day-Care Centers,” American Journal of Epidemiology 113(4):
445-451,1981.
Black, R.E., “Diarrheal Diseases and Child Morbidity and Mortality,” Child Survival: Strategies for Research, Population
and Development Review, Supplement to Vol. 10, L.C. Chen, H. Mosely (ed.) (New York: The Population Council, 1984).
Black, R.E., K.H. Brown, S.Becker, “Malnutrition is a Determining Factor in Diarrheal Duration, but not Incidence, among
Young Children in a Longitudianl Study in Rural Bangladesh,” The American Journal of Clinical Nutrition, 37:87-94,
January, 1984.
Brown, K.H., W.C. MacLean, “Nutritional Management of Acute Diarrhea: An Appraisal of the Alternatives,” Pediatrics,
73(2): 119-125, February, 1984.
Chen, L.C., M. Rahman, A.M. Sarder, “Epidemiology and Causes of Death among Children in a Rural Area of Bangladesh,”
International Journal of Epidemiology, 9(1): 25-33,1980.
Chen, L.C., “Interactions of Diarrhea and Malnutrition: Mechanisms and Interventions,” Diarrhea and Malnutrition, L.C.
Chen and N.S. Scrimshaw (ed.) (Tokyo, Japan: Plenum Press, 1983), pp. 3-19.
De Zoysa, L, R.G. Feachem, “Interventions for the Control of Diarrhoeal Diseases among Young Children:
Chemoprophylaxis,” Bulletin of the World Health Organization, 63(2): 295-315, Geneva, Switzerland, 1985.
Esrey, S.A., R.G. Feachem, J.M. Hughes, “Interventions for the Control of Diarrhoeal Diseases among Young Children:
Improving Water Supplies and Excreta Disposal Facilities,” Bulletin of the World Health Organization, 63(4): 757-772,
Geneva, Switzerland, 1985.
Feachem, R.G., “Interventions for the Control of Diarrhoeal Diseases among Young Children: Supplementary Feeding
Programs,” Bulletin of the World Health Organization, 61(6): 967-979, Geneva, Switzerland, 1983.
Feachem, R.G., “ Interventions for the Control of Diarrhoeal Diseases among Young Children: Promotion of Personal and
Domestic Hygiene,” Bulletin of the World Health Organization, 62(3): 467-476, Geneva, Switzerland, 1984.
Feachem, R.G., R.C. Hogan, M.H. Merson, “Diarrhoeal Disease Control: Reviews of Potential Interventions,” Bulletin of
the World Health Organization, 61(4): 637-640, Geneva, Switzerland, 1983.
Feachem, R.G., M. A. Koblinsky, “Interventions for the Control of Diarrhoeal Diseases among Young Children: Promo
tion of Breastfeeding,” Bulletin of the World Health Organization, 62(2): 271-291, Geneva, Switzerland, 1984.
Feachem, R.G., M.A. Koblinsky, “Interventions for the Control of Diarrhoeal Diseases among Young Children: Measles
Immunization,” Bulletin of the World Health Organization, 62: 641-652, Geneva, Switzerland, 1984.
Koster, FT, G.C. Curlin, K.M.A. Aziz, A. Haque, “Synergistic Impact of Measles and Diarrhoea on Nutrition and Mortality
in Bangladesh,” Bulletin of the World Health Organization, 59(6): 901-908, Geneva, Switzerland, 1981.
Monto, AS., J.S. Koopman, “The Tecumseh Study. XI. Occurrence of Acute Enteric Illness in the Community,” American
Journal of Epidemiology, 112(3): 323-333, 1980.
Nagaty, A., “Oral Rehydration Cuts Child Mortality From Diarrhea in Half,” Diarrhea Control Newsletter, 1: 10-11,1983.
Parker, R.L., W. Rinehart, P.T Piotrow, L. Doucette, “Oral Rehydration Therapy (ORT) for Childhood Diarrhea,” Population
Reports, series L, No.2, Population Information Program, The Johns Hopkins University, Baltimore, Md., 1985.
66
Rowland, M.G.M., “Epidemiology of Childhood Diarrhea in The Gambia,” Diarrhea and Malnutrition, L.C. Chen, N.S.
Scrimshaw (ed.) (Tokyo, Japan: Plenum Press, 1983), pp. 87-97.
Sahni, S., R.K. Chandra, “Malnutrition and Susceptibility to Diarrhea: With Special Reference to the Antiinfective Prop
erties of Breast Milk,” Diarrhea and Malnutrition, L.C. Chen, N.S. Scrimshaw (ed.) (Tokyo, Japan: Plenum Press, 1983),
pp. 99-109.
Snyder, J.D., M.H. Merson, “The Magnitude of the Global Problem of Acute Diarrhoeal Disease: A Review of Active
Surveillance Data,” Bulletin of the World Health Organization, 60(4): 605-613, Geneva, Switzerland, 1982.
World Health Organization Scientific Working Group, “Parasite-Related Diarrhoeas.” Bulletin of the World Health
Organization, 58(6): 819-830, Geneva, Switzerland, 1980.
World Health Organization, “CDD Morbidity, Mortality, and Treatment Survey Results,” Program for Control of Diar
rhoeal Diseases, Geneva, Switzerland,. 1985.
World Health Organization, “Fourth Programme Report for Control of Diarrhoeal Diseases 1983-1984,” Program for
Control of Diarrhoeal Diseases, Geneva, Switzerland, 1985.
World Health Organization, “ORA Use and Access in 1983,” Program for Control of Diarrhoeal Diseases, Geneva,
Switzerland, 1985.
World Health Organization, “CDD Estimates of ORS Access and ORS/ORT Use in 1984,” Program for Control of Diarrhoeal
Diseases, Geneva, Switzerland, 1985.
Selected Bibliography: Vaccine-Preventable Diseases
Cook, R., “Pertussis in Developing Countries: Possibilities and Problems of Control through Immunization,” The Third
International Symposium on Pertussis, C.R. Manclark andJ.C. Hill (ed.) (Washington, D.C.: Dept, of Health, Education
and Welfare, Public Health Service, National Institutes of Health, 1979).
Foster, S.O., “Immunizable and Respiratory Diseases and Child Mortality,” Child Survival: Strategies for Research, Population
and Development Review, Supplement to Vol. 10, L.C. Chen, H. Mosely (ed.) (New York: The Population Council, 1984).
Henderson, R.H., “Vaccine Preventable Diseases of Children: The Problem,” in Protecting the World’s Children: Vaccines
and Immunization, A Bellagio Conference (New York: The Rockefeller Foundation, 1984).
Koster, FT, G.C. Curlin, K.M.A. Aziz, A. Hague, “Synergistic Impact of Measles and Diarrhea on Nutrition and Mortality
in Bangladesh,” Bulletin of the World Health Organization, 59(6): 901-908, Geneva, Switzerland, 1981.
LaForce, EM., M.S. Lichnevski, J. Keja, R.H. Henderson, “Clinical Survey Techniques to Estimate Prevalence and Annual
Incidence of Poliomyelitis in Developing Countries,” Bulletin of the World Health Organization, 58(4): 609-620, Geneva,
Switzerland, 1980.
Sherris, J.D., R. Blackbum, S.H. Moore, S. Mehta, “Immunizing the World’s Children,” Population Reports, Series L, No. 5,
Population Information Program, The Johns Hopkins University, Baltimore, Md. March-April, 1986.
Stansfield, J.P., A. Galazka, “Neonatal Tetanus in the World Today,” Bulletin ofthe World Health Organization, 62(4): 647-669,
Geneva, Switzerland, 1984.
World Health Organization, “Expanded Program on Immunization: Global Status Report,” Weekly Epidemiological Record,
60(34): 261-268, Geneva, Switzerland, 1985.
67
World Health Organization, “The WHO’s Expanded Programme on Immunization: A Global Overview 1985,” World Health
Statistics Quarterly, 38: 232-252 Geneva, Switzerland, (1986).
Selected Bibliography: Acute Respiratory Infection
Foster, S.O., “Immunizable and Respiratory Diseases and Child Mortality,” Child Survival: Strategies for Research, Population
and Development Review, Supplement to Vol. 10, LC. Chen, H. Mosely (ed.) (New York: The Population Council, 1984).
LeowskiJ., “Worldwide Mortality from Acute Respiratory Infections in Children Under 5 Years of Age,” Submitted for
pubheation, World Health Statistics Quarterly, Geneva, Switzerland, 1986.
Miller, D.L, “Issues for the Future of ARI Control,” Acute Respiratory Infections in Childhood, Proceedings of an Inter
national Workshop, Sydney, Australia (1984), R. Douglas, E. Kerby-Eaton (ed.) (Adelaide, Australia: University of Adelaide,
1985).
Parker, R.L., “Primary Health Care Interventions for Acute Respiratory Illness in Children,” Paper presented at a Seminar
on ARI, FKMUI, Jakarta, Indonesia, 11 February, 1985.
Pio, A., et al., “The Magnitude of the Problem of Acute Respiratory Infections,” Acute Respiratory Infections in Childhood,
Proceedings of an International Workshop, Sydney, Austraha (1984), R. Douglas, E. Kerby-Eaton (ed.) (Adelaide, Australia:
University of Adelaide, 1985).
Riley, I., “The Aetiology of Acute Respiratory Infections in Children in Developing Countries,” Acute Respiratory Infections
in Childhood, Proceedings of an International Workshop, Sydney, Australia (1984), R. Douglas, E. Kerby-Eaton (ed.)
(Adelaide, Australia: University of Adelaide, 1985).
Sommer, A., G. Hussaini, I. Tarwotjo, “Increased Mortality in Children with Mild Vitamin A Deficiency,” The Lancet, 10:
585-588, September, 1983.
Sommer, A., J. Katz, I. Tarwotjo, “Increased Risk of Respiratory Disease and Diarrhea in Children with Pre-existing Mild
Vitamin A Deficiency,” American Journal of Clinical Nutrition, 40,1984.
Tupasi, T.E., “Nutrition and Acute Respiratory Infection,” Acute Respiratory Infections in Childhood, Proceedings of an
International Workshop, Sydney, Australia (1984), R. Douglas, E. Kerby-Eaton (ed.) (Adelaide, Australia: University of
Adelaide, 1985).
World Health Organization, “A Programme for Controlling Acute Respiratory Infections in Children: Memorandum from
a WHO Meeting,” Bulletin of the World Health Organization, 62(1): 47-58, Geneva, Switzerland, 1984.
Selected Bibliography: Malaria
Brabin, B.J., “An Analysis of Malaria in Pregnancy in Africa,” Bulletin of the World Health Organization, 61(6): 1005-1016,
Geneva, Switzerland, 1983
Bradley, D., A. Keymer, “Parasitic Diseases: Measurement and Mortality Impact,” Child Survival; Strategies for Research,
Population and Development Review, Supplement to Vol. 10, LC. Chen, H. Mosely (ed.) (New York: The Population Council,
1984).
Ghana Health Assessment Project Team, “A Quantitative Method of Assessing the Health Impact of Different Diseases
in Less Developed Countries,” International Journal of Epidemiology, 10(1): 73-80,1981.
68
Miller, L.H., “Malaria,” Tropical and Geographical Medicine, K.S. Warren, A.A. Mahmoud (ed.) (New York: McGraw-Hill,
1984).
Payne, D., B. Grab, R.E. Fontaine, J.H.G. Hempel, “Impact of Control Measures on Malaria Transmission and General
Mortality,” Bulletin of the World Health Organization, 54: 369-377, Geneva, Switzerland, 1976.
Pawlowski, Z.S., “Implications of Parasite-Nutrition Interactions from a World Perspective,” From the Symposium Nutrition
and Parasitic Infection presented by the American Institute of Nutrition, New Orleans, Louisiana, April 16,1982, Federation
Proceedings 43(2): 256-260, February, 1984.
)
World Health Organization, “Recent Progress in the Development of Malaria Vaccines: Memorandum from a WHO
Meeting,” Memorandum from the Scientific Working Group in the Immunology of Malaria, held in Geneva on 26-28 March
1984, Bulletin of the World Health Organization, 62(5): 715-726, Geneva, Switzerland, 1984.
World Health Organization, Tropical Disease Research, Seventh Programme Report, 1985.
World Health Organization, “World Malaria Situation 1983,” World Health Statistics Quarterly, 38: 193-231, Geneva,
Switzerland, 1985.
World Health Organization, “World Malaria Situation 1984,” World Health Statistics Quarterly, 39, Geneva, Switzerland,
1986.
Selected Bibliography: Malnutrition
Cameron, M., Y. Hofvander, Manual on Feeding Infants and Young Children, Oxford University Press, Delhi, 1983.
Chen, L.C., A. Chowdhury, S.L Huffman, “Anthropometric Assessment of Energy-protein Malnutrition and Subsequent
Risk of Mortality among Preschool Aged Children,” American Journal of Clinical Nutrition, 33: 1836-1845,1980.
Chen, L.C., N.S. Scrimshaw (ed.), Diarrhea and Malnutrition, United Nations University, Tokyo, Japan, 1983.
Chen, L.C., H. Mosely (ed.), Child Survival: Strategies for Research, Population and Development Review, Supplement to
Vol. 10,1984.
Douglas R., E. Kerby-Eaton (ed.), Acute Respiratory Infections in Childhood: Proceedings of an International Workshop,
University of Adelaide, Adelaide, Australia, 1984.
Friede, AM., S. Becker, P.H. Rhodes, “The Comparison of Infant Mortality Rates When Birthweight Distribution Differs,”
(Unpublished article), Centers for Disease Control, Atlanta, Ga.
Haaga, J., C. Kenrick, K. Test, J. Mason, “An Estimate of the Prevalence of Child Malnutrition in Developing Countries,”
World Health Statistics Quarterly, 38, Geneva, Switzerland, 1985.
Institute of Medicine, “Preventing Low Birthweight: Summary,” Committee to Study the Prevention of Low Birthweight,
National Academy Press, Washington, D.C., 1985.
Keller, W, C.M. Fillmore, “Prevalence of Protein-Energy Malnutrition,” World Health Statistics Quarterly, 36(2), Geneva,
Switzerland, 1983.
Kielmann, A.A., C. McCord “Weight-for-Age as an Index of Risk of Death in Children,” Lancet, June 10,1978.
69
Mata, L., et al., “Promotion of Breast-Feeding, Health, and Growth among Hospital-Bom Neonates, and among Infants of
a Rural Area of Costa Rica,” Diarrhea and Malnutrition, L.C. Chen, N.S. Scrimshaw (ed.) (Tokyo, Japan: Plenum Press),
pp. 177-203.
Prosterman, R.L, “The Decline in Hunger-Related Deaths,” Hunger Project Papers 1, San Francisco, Ca., 1984.
Puffer, RR, C.V Serano, (ed.) Patterns of Mortality in Childhood, Pan American Health Organization, Scientific Publication
262, Washington, D.C, 1973.
Rowland, M.G.M., “Epidemiology of Childhood Diarrhea in The Gambia,” Diarrhea and Malnutrition, LC. Chen, N.S.
Scrimshaw (ed.) (Tokyo, Japan: Plenum Press, 1983), pp. 87-97.
Royston, E., “The Prevalence of Nutritional Anaemia in Women: A Critical Review of Available Information,” World Health
Statistics Quarterly, 35(2), Geneva, Switzerland, 1982.
Scrimshaw, N.S., C.E. Taylor, J.E. Gordon, “Interactions of Nutrition and Infection,” World Health Organization, Monograph
Series No. 57, Geneva, Switzerland, 1968.
Sommer, A., Nutritional Blindness, Oxford University Press, New York, 1982.
Sommer, A, G. Hussaini, I. Tarwotjo, D. Susanto, “Increased Mortality in Children with Mild Vitamin A Deficiency,” Lancet,
September 10,1983.
Sommer, A., J. Katz, I. Tarwotjo, “Increased Risk of Respiratory Disease and Diarrhea in Children with Preexisting Mild
Vitamin A Deficiency,” The American Journal of Clinical Nutrition, November, 1984.
World Health Organization, “The Incidence of Low Birth Weight: A Critical Review of Available Information,” World Health
Statistics Quarterly, 33(3): 197-224, Geneva, Switzerland, 1982.
World Health Organization, “The Prevalence and Duration of Breast-Feeding: A Critical Review of Available Information,”
World Health Statistics Quarterly, 35(2): 92-116, Geneva, Switzerland, 1982.
World Health Organization, “The Prevalence of Anaemia in the World,” World Health Statistics Quarterly, 38: 289-301,
Geneva, Switzerland, 1985.
World Health Organization, “The Epidemiology of Perinatal Mortality,” World Health Statistics Quarterly, 38: 302-316,
Geneva, Switzerland, 1985.
World Health Organization, “The Incidence of Low Birth Weight: An Update,” Weekly Epidemiologic Record, 59,27: 205-212,
Geneva, Switzerland, 1984.
World Health Organization, “Vitamin A: Let there be sight,” In Point of Fact, 29, WHO, Geneva, Switzerland, 1985.
Selected Bibliography: High-Risk Fertility Behavior
Casterline, J.B., J. Trussel. “Age at First Birth,” World Fertility Survey Comparative Studies No. 15, International Statistical
Institute, Voorburg, Netherlands, 1980.
Gubhaju, B.B., “The Effect of Previous Child Death on Infant and Child Mortality in Rural Nepal,” Studies in Family Planning,
16(4): 231-236, The Population Council, New York, July/August, 1985
70
(
Hobcraft, J.N.J.W McDonald, S.O. Rutstein, “Child-Spacing Effects on Infant and Early Child Mortality,” Population Index,
49(4): 585-618, Princeton University, N.J., 1983.
Hobcraft, J.N.J.W. McDonald, S.O. Rutstein, “Demographic Determinants of Infant and Early Child Mortality: A Com
parative Analysis,” Population Studies, 39: 363-385,1985.
London, K.A., et al., “Fertility and Family Planning Surveys: An Update,” Population Reports, series M, No. 8, Population
Information Program, The Johns Hopkins University, Baltimore, Md., September-October 1985.
Maine, D., “Family Planning: Its Impact on the Health of Women and Children,” Center for Population and Family Health,
Columbia University, New York, 1981.
Maine, D., et al., “Effects of Fertility Change on Maternal and Child Survival: Prospects for Subsaharan Africa,” report
prepared for the Policy and Research Division, Population, Health and Nutrition Department, The World Bank,
Washington, D.C., 1985.
Maine, D., R. McNamara, “Birth Spacing and Child Survival,” Center for Population and Family Health, Columbia Uni
versity, New York, 1985.
McCann, M.E, et al., “Breast-Feeding, Fertility, and Family Planning,” Population Reports, series J, No. 24, Population
Information Program, The Johns Hopkins University, Baltimore, Md., November-December 1981.
Omran, A.R., A.G. Johnston, Family Planning for Health in Africa. Carolina Population Center, Chapel Hill, N.C., 1984.
Rinehart, W., A. Kols, S.H. Moore, “Healthier Mothers and Children Through Family Planning,” Population Reports, series
J, No. 27, Population Information Program, The Johns Hopkins University, Baltimore, Md., May-June 1984.
Rutstein, S.O., “Infant and Child Mortality: Levels, Trends and Demographic Differentials,” Revised Edition, World Fertility
Survey Comparative Studies No. 43, International Statistical Institute, Voorburg, Netherlands, 1984.
Trussell, J., A.R. Pebley, “The Potential Impact of Changes in Fertility on Infant, Child and Maternal Mortality,” World Bank
Staff Working Papers No. 698, Population and Development Series Number 23, The World Bank, Washington, D.C., 1984.
Selected Bibliography: Education and Literacy
Caldwell, J.C., “Education as a Factor in Mortality Decline, An Examination of Nigerian Data,” Population Studies, 33(3):
395-413,1979.
Caldwell, J.C., P. McDonald, “Influence of Maternal Education on Infant and Child Mortality: Levels and Causes, “Inter
national Population Conference, 2: 79-95, Manila, 1981.
Cochrane, S.H., DJ. O’Hara, J. Leslie, “The Effects of Education on Health,” World Bank Staff Working Papers No. 405, The
World Bank, Washington, D.C., 1980.
Cochrane, S.H., J. Leslie, DJ. O’Hara, “Parental Education and Child Health: Intracountry Evidence,” Health Policy and Educa
tion, 2: 213-250, Elsevier Scientific Publishing Company, Amsterdam, 1982.
Cochrane, S.H., “The Effect of Education on Mortality: A Quick Review of the Evidence,” World Bank Paper, The World
Bank, Washington, D.C., 1985.
Gbolahan, A.O., “Effects of Women’s Education on Postpartum Practices and Fertility in Urban Nigeria,” Studies in Family
Planning, 16(6): 321-331, The Population Council, New York, November/December, 1985.
71
Hobcraft, J.N., JW McDonald, S.O. Rutstein, “Socio-economic Factors in Infant and Child Mortality: A Cross-national
Comparison,” Population Studies 38(2): 193-223,1984.
Selected Bibliography: Availability of Modem Health Services
Golladay, F., “Health,” A Sector Policy Paper, The World Bank, Second Edition. Washington, D.C., February, 1980.
Gunatilleke, G., “Health and Development in Sri Lanka: An Overview,” Good Health at Low Cost, S.B. Halstead, J.A. Walsh,
K.S. Warren, (ed.) (New York: The Rockefeller Foundation, 1985).
Mosely, H., “Child Survival: Research and Policy,” Child Survival: Strategies for Research, Population and Development
Review, Supplement to Vol. 10, L.C. Chen, H. Mosely (ed.) (New York: The Population Council, 1984).
Nag, M., “The Impact of Social and Economic Development on Mortality: Comparative Study of Kerala and West Bengal,”
Good Health at Low Cost, S.B. Halstead, J.A. Walsh, K.S. Warren, (ed.) (New York: The Rockefeller Foundation, 1985).
Rohde, J.E., “Why the Other Half Dies: The Science and Politics of Child Mortality in the Third World,” A Child Survival
and Development Revolution, PE. Mandi (ed.) (Switzerland: UNICEF, 1983).
Selected Bibliography: Income Per Capita and Government Expenditures
Hobcraft, J.N., J.W. McDonald, S.O. Rutstein, “Socio-economic Factors in Infant and Child Mortality: A Cross-National
Comparison,” Population Studies, 38(2): 193-223 1984.
Preston, S. H., Mortality Patterns in National Populations. Academic Press. New York. 1976.
World Bank. World Bank Development Report. Washington, DC. 1985.
Halstead, S.B., J.A. Walsh, K.S. Warren, (eds.) Good Health at Low Cost. Conference Report, the Rockefeller Foundation.
New York, N.Y. 1985.
Selected Bibliography: Food Availability
Foege, W.H., “Remarks,” Good Health at Low Cost, S.B. Halstead, J.A. Walsh, K.S. Warren, (ed.) (New York: The Rockefeller
Foundation, 1985).
Martorell, R., Sharma, R., “Trends in Nutrition, Food Supply and Infant Mortality Rates,” Good Health at Low Cost, S.B.
Halstead, J.A. Walsh, K.S. Warren, (ed.) (New York: The Rockefeller Foundation, 1985).
Mosely, H., “Health, Nutrition, and Mortality in Bangladesh,” Research in Human Capital and Development, 1: 77-94, JA1
Press, Inc., 1979.
Reutlinger, S., J. Pellekaan, “Poverty and Hunger: Issues and Options for Food Security in Developing Countries,” World
Bank Policy Study, The World Bank, Washington, D.C., 1986.
72
Selected Bibliography: Water Supply and Sanitation Facilities
Blum, D., R.G. Feachem, “Measuring the Impact of Water Supply and Sanitation Investments on Diarrheal Diseases: Prob
lems of Methodology.” InternationalJournal of Epidemiology, 12(3): 357-365,1983.
Briscoe, J., “Water Supply and Health in Developing Countries: Selective Primary Health Care Revisited,” American Journal
of Public Health, 74(9): 1009-1013,1984.
Briscoe, J., “Evaluating Water Supply and Other Health Programs: Short-Run vs Long-Run Mortality Effects,” Public Health
London, 99: 142-145,1985.
Briscoe, J., R.G. Feachem, M.M. Rahaman, “Measuring the Impact of Water Supply and Sanitation Investments on Diar
rhoeal Diseases: Problems of Methodology,” World Health Organization, Geneva, 71 pp., 1985.
Esrey, S.A., R.G. Feachem, J.M. Hughes, “Interventions for the Control of Diarrhoeal Diseases Among Young Children:
Improving Water Supplies and Excreta Disposal Facilities,” Research Bulletin ofthe World Health Organization, 63(4), Geneva,
Switzerland, 757-772,1983.
Feachem, R.G., et al., “Health Aspects of Excreta and Sullage Management—A State of the Art Review,” World Bank,
Washington D.C., 318 pp., 1981.
International Bank for Reconstruction and Development. “Measurement of the Health Benefits of Investments in Water
Supply,” Report of an Expert Panel to the International Bank for Reconstruction and Development, PUN Report No. 20,
12 pp., 1976.
McJunkin, F.E., “Water and Human Health,” Agency for International Development, Washington D.C., 134 pp., 1982.
National Research Council, “Drinking Water and Health,” 4 vols., Washington D.C., 939 pp., 1977; 393 pp., 1980; 415
pp., 1980, and 299 pp., 1982.
United Nations, “Progress on the Attainment of the Goals of the International Drinking Water Supply and Sanitation
Decade, Report of the Secretary General,” General Assembly, Economic and Social Council, A/40/108/E/1985/49,1985.
World Health Organization, “Maximizing Benefits to Health, An Appraisal Methodology for Water Supply and Sanita
tion Projects,” Geneva, 44 pp., 1983.
73
Appendices
Child Survival Statistics
Methodology of Projections
Definitions and Sources of Data
Countries and Regions
75
Table 1: Numbers of Infants and Children Age 1-4
if 1980-85 Mortality Levels Continue (in Thousands)
Africa
Age 1-4
1985
1990
Infants_____
1995
2000
1985
1990
1995
2000
19,606.3
22,661.0
25,950.6
28,046.1
65,904.8
76,517.2
88,109.0
101,624.7
369.6
474.0
248.1
69.1
376.3
247.7
501.4
127.7
247.8
92.5
2,443.0
50.7
32.8
800.7
311.3
39.1
552.4
1,509.4
71.9
129.8
541.1
429.7
458.7
110.0
22.5
719.5
83.0
368.7
6,087.0
11.6
378.8
343.4
172.8
244.9
1,372.8
1,069.0
36.9
1,453.8
161.9
978.0
1,634.9
409.5
536.1
507.6
268.9
75.6
403.0
261.8
539.7
135.8
262.8
99.0
2,616.4
51.9
1,380.0
726.6
1,567.6
837.4
246.3
1,239.7
848.7
1,732.3
427.5
831.1
330.4
8,027.5
181.1
876.0
330.2
41.1
597.8
1,663.0
76.5
142.8
581.7
460.1
493.4
117.7
21.8
767.9
89.2
399.3
6,664.6
11.5
411.8
367.8
180.3
262.8
1,425.5
1,117.2
40.1
1,599.6
174.6
1,070.4
1,766.1
449.4
588.9
1,213.6
626.5
179.9
971.5
677.5
1,339.3
343.0
662.2
255.2
6,294.5
123.5
92.9
2,002.4
821.9
109.2
1,379.5
3,590.4
204.1
316.0
1,491.8
1,029.2
1,116.4
279.8
99.2
1,814.4
215.8
911.8
14,617.3
42.0
930.8
886.0
480.8
641.0
4,209.3
3,039.3
91.9
3,436.2
420.4
2,382.3
4,209.6
1,025.9
1,330.4
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
Zaire
Zambia
Zimbabwe
186.9
50.9
296.4
199.6
389.0
102.9
199.3
72.2
1,924.7
37.4
27.3
588.4
252.1
32.6
406.7
1,047.3
57.9
95.7
416.6
326.1
355.4
85.0
24.7
559.5
63.8
279.1
4,389.6
10.9
281.5
268.6
149.0
195.7
1,158.6
888.4
27.7
1,034.2
123.1
711.7
1,238.4
297.1
384.6
419.9
216.0
59.6
334.9
223.2
442.4
114.9
223.3
82.1
2,173.5
44.9
30.1
689.5
281.5
35.9
478.3
1,266.0
64.8
111.2
476.6
378.5
405.2
97.6
23.8
639.5
73.1
321.8
5,195.9
11.4
326.4
305.0
161.0
219.4
1,274.6
982.4
32.1
1,231.4
141.8
838.2
1,427.2
349.6
456.2
Near East
8,822.3
9,370.7
9,644.2
9,746.7
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
848.6
12.9
1,517.1
1,622.5
633.4
93.1
151.1
64.0
76.4
149.1
704.7
50.9
446.6
455.9
210.4
928.1
939.4
11.4
1,493.4
1,740.5
745.1
96.4
226.6
74.4
82.9
195.3
651.5
62.3
602.7
574.4
203.9
1,410.2
35.0
916.7
11.2
1,493.1
1,729.9
778.4
97.0
249.8
74.9
82.9
207.5
624.1
65.6
651.7
596.0
198.7
1,397.2
36.2
120.3
415.3
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
76
1,364.0
34.0
90.4
297.4
12.0
1,512.5
1,721.5
689.0
94.3
187.9
70.6
80.1
172.5
692.2
57.1
522.8
524.2
211.4
1,420.0
34.7
103.3
336.5
115.0
383.9
34.5
102.6
112.5
2,365.5
924.3
l’21.1
1,636.8
4,354.9
229.3
366.0
1,711.8
1,209.0
1,279.1
325.5
97.1
2,089.9
248.2
1,054.3
17,383.7
45.1
1,073.2
1,011.5
522.5
724.4
4,683.9
3,386.0
106.7
4,104.7
486.6
2,821.6
4,856.0
1,210.5
1,586.3
2,746.4
1,023.9
132.4
1,909.7
5,256.6
255.2
426.2
1,954.0
1,387.2
1,451.2
368.6
91.9
2,370.4
283.2
1,211.5
20,489.8
46.3
1,255.5
1,142.1
560.8
803.5
5,093.4
3,718.8
123.0
4,874.3
558.1
3,303.4
5.597.2
1,420.8
1,871.6
1,777.7
971.0
290.4
1,406.6
939.3
1,983.4
478.3
926.2
373.8
9,105.8
188.9
123.2
3,239.9
1,141.4
144.8
2,208.6
6,282.4
285.5
507.9
2,231.9
1,572.9
1,659.0
417.3
86.3
2,671.7
323.5
1,402.9
24,208.5
45.9
1,464.0
1,296.1
606.4
914.7
5,458.4
4,032.3
143.3
5,811.1
641.6
3,900.0
6,450.4
1,686.4
2,224.8
31,934.7
34,619.4
35,996.6
36,678.1
3,014.9
53.2
5,607.5
5,720.0
2,326.9
370.8
526.3
240.8
294.1
517.2
2,628.6
173.0
1,591.9
1,637.3
787.1
5,024.3
130.8
298.4
991.8
3,415.5
49.7
5,675.6
6,244.7
2,535.2
371.1
663.4
270.0
306.0
601.2
2,659.9
198.4
1,874.8
1,927.5
815.6
5,415.8
139.0
342.5
1,113.3
3,613.3
46.2
5,545.9
6,426.7
2,754.3
382.4
816.6
294.3
326.2
694.7
2,525.9
216.5
2,183.6
2,166.2
790.7
5,415.9
134.3
391.4
1,271.5
3,454.9
44.9
5,544.2
6,354.7
2,984.8
387.2
977.1
298.2
326.0
776.3
2,334.9
238.4
2,521.2
2,318.1
754.1
5,325.4
143.0
425.7
1,469.1
212.6
1,101.4
757.0
1,525.1
383.6
745.7
291.2
7,126.3
149.8
Infants
Age 1-4
1990
1990
1995
2000
1985
Asia (without China)
43,953.1
44,297.8
44,340.7
43,845.0
162,899.0
163,209.5
166,033.4
162,600.8
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
726.3
3,977.3
48.3
1,039.0
26.4
19.6
90.3
813.3
887.4
4,391.9
52.8
1,074.7
23.1
1,271.5
1,703.4
2,500.0
14,737.2
178.6
4,097.9
93.0
77.0
378.6
76,059.7
17,595.5
1,019.8
2,412.0
3,882.4
559.2
1,716.5
652.5
45.7
263.7
2,219.1
482.4
14,425.9
6,578.5
69.5
171.6
1,567.6
4,702.9
6,722.7
2,888.4
15,757.3
188.5
4,146.1
79.6
64.8
357.0
74,195.8
16,920.0
777.7
2,515.9
3,425.1
3,930.6
1,722.7
16.6
39.8
342.4
1,384.0
1,823.8
2,233.7
13,837.7
166.9
3,929.7
89.8
79.6
345.8
78,494.9
18,050.6
977.0
2,247.8
3,498.2
531.6
1,750.7
625.9
45.0
237.5
2,093.8
462.1
13,395.1
6,318.5
69.1
166.9
1,688.1
5,215.8
6,347.3
2,828.6
70.8
644.3
129.6
3,969.8
1,719.9
17.3
42.7
378.3
1,252.7
1,797.8
877.4
4,347.5
52.0
1,078.3
24.8
16.7
92.5
20,501.0
4,620.3
246.8
629.8
894.4
160.0
412.6
177.4
11.7
76.5
684.8
137.0
3,967.2
1,735.0
16.9
41.3
350.9
1,347.3
1,840.8
China
19,096.9
19,708.2
20,412.8
20,802.2
74,085.0
21,017.3
4,753.1
282.0
586.8
923.7
149.2
438.2
163.6
11.6
64.0
604.2
123.3
3,796.9
1,665.4
17.4
42.3
411.9
4,202.1
50.7
1,070.6
26.5
18.2
94.8
20,693.3
4,691.7
278.6
616.8
950.0
156.0
429.6
170.5
11.6
16.3
89.4
20,149.3
4,507.0
220.9
635.3
864.9
160.7
395.2
181.3
11.7
78.8
703.3
141.1
1995
2000
1985
15,466.8
183.7
4,171.0
90.6
67.6
379.8
76,585.5
17,707.5
952.2
2,476.1
3,641.8
582.6
587.1
5,177.9
7,112.0
1,563.4
708.2
45.9
308.0
2,511.0
541.0
14,349.0
6,663.8
65.8
158.6
1,351.2
5,439.7
6,992.0
76,071.6
79,030.7
81,818.6
1,691.2
680.4
45.7
291.9
2,391.1
511.9
14,595.0
6,751.1
68.1
170.1
1,413.5
Latin America & Caribbean
11,696.4
12,185.0
12,454.9
12,574.2
44,104.0
46,511.0
47,776.5
48,577.4
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
705.8
252.0
3,780.8
262.1
825.9
74.9
171.9
187.9
317.8
204.5
312.8
24.6
245.6
170.1
62.1
2,447.6
131.9
57.9
710.5
706.1
280.5
3,884.7
271.0
851.0
77.9
188.4
193.4
349.7
224.9
343.7
23.4
275.8
184.0
60.4
2,525.5
310.5
3,905.2
707.6
329.5
3,904.1
269.2
851.0
78.7
192.1
189.4
390.1
263.3
393.2
21.7
2,832.6
961.7
14,919.7
2,792.9
1,067.5
15,070.2
1,086.4
3,327.7
2,803.4
1,190.2
Less Developed
More Developed
103,175.1
17,652.4
108,222.7
Sweden
Japan
United States
89.5
1,527.9
3,719.1
83.4
1,527.3
3,797.2
World Total
120,827.5
125,888.7
123.5
650.0
72.3
28.6
56.3
529.5
145.9
60.7
134.0
681.1
73.9
28.5
56.5
559.5
17,666.0
853.0
78.6
193.7
192.1
376.5
248.1
374.8
22.3
309.1
210.2
57.0
2,555.1
157.6
61.9
141.4
693.2
73.1
27.3
56.8
580.2
55.4
2,555.2
163.8
61.9
145.1
694.7
72.0
26.5
57.0
590.8
2,769.2
861.7
14,303.6
1,017.6
3,143.1
289.5
646.7
709.5
1,163.8
749.9
1,129.1
99.7
841.0
626.3
247.4
9,352.7
474.6
222.9
460.7
2,350.7
282.5
112.5
223.3
2,025.7
112,803.3
17,581.0
115,014.2
17,517.5
82.4
271.3
1,072.1
3,303.5
308.6
730.2
744.4
1,293.7
823.4
312.4
777.2
750.6
1,409.7
15,062.6
1,070.5
3,313.8
313.3
765.6
731 0
224.1
2,167.7
2,578.7
294.8
111.6
224.8
2,259.0
1,504.9
1,012.2
1,490.2
85.7
1,200.3
874.6
220.2
9,958.1
623.7
245.2
567.9
2,589.5
287.2
105.3
226.5
2,335.4
378,927.5
70,260.1
396,928.8
70,595.5
416,946.2
70,326.1
431,299.7
69,861.6
3,799.8
81.4
1,699.1
3,764.4
378.5
6,202.8
14,647.9
334.2
5,948.4
15,071.1
332.5
6,230.8
15,287.7
325.3
6,783.0
15,027.8
130,384.3
132,531.7
449,187.6
467,524.3
487,272.3
501,161.3
1,622.3
330.6
231.3
1,244.6
95.2
944.9
656.4
248.2
9,747.4
531.9
236.6
508.6
2,504.7
295.0
115.6
907.6
1,364.6
90.0
1,060.8
733.4
231.8
9,957.1
581.1
244.9
541.6
77
Table 2: Percent and Numbers of Children Dying Before Age 1 and Age 5
if 1980-85 Mortality Levels Continue
Annual number of infant and child deaths
if 1980-85 mortality levels continue
(in thousands)
1980-85 mortality,
percent of children
dying
Before
agel
Before
age 5
Africa
11.9
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
Zaire
Zambia
Zimbabwe
14.9
12.0
7.6
15.0
12.4
10.3
14.2
14.3
8.1
15.5
11.2
17.4
9.8
15.9
14.3
11.0
8.0
11.1
13.2
6.7
16.3
18.0
13.7
2.8
15.3
11.6
14.6
11.4
1.3
13.2
14.2
18.0
15.5
8.3
11.8
12.9
11.5
10.2
11.2
10.7
8.8
8.0
Near East
9.3
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
78
8.8
1.7
10.0
11.5
7.7
1.4
5.4
2.3
4.8
9.7
9.7
11.7
6.6
5.9
8.5
9.2
3.8
13.5
13.5
Infants
Age 1-4
1985
1990
1995
2000
1985
1990
1995
2000
19.7
2,538.8
2,928.0
3,346.8
3,613.7
1,555.4
1,783.9
2,050.4
2,362.6
25.0
20.0
10.5
25.5
21.0
17.0
24.0
24.0
13.0
26.0
18.6
23.2
16.0
27.0
24.0
16.5
13.0
15.0
22.5
10.5
28.5
31.0
23.0
3.6
26.0
19.3
24.5
19.0
1.7
22.5
24.0
31.0
26.0
11.0
20.0
21.9
19.0
17.0
18.5
18.0
14.0
13.0
60.9
24.4
4.1
49.5
27.0
43.1
16.1
31.4
332.0
4.5
5.4
61.9
44.8
5.1
48.2
89.2
6.9
13.9
29.4
59.7
72.4
12.8
0.7
95.6
8.0
45.0
542.1
0.1
40.7
42.2
30.3
33.8
102.5
113.4
3.9
128.4
13.5
86.0
143.0
27.9
32.7
69.2
28.2
4.8
55.9
30.2
49.0
18.0
35.2
7.1
374.9
5.4
5.9
72.5
50.1
5.7
56.7
107.8
7.8
16.1
33.6
69.3
82.5
14.7
0.7
109.2
9.2
51.9
641.6
0.2
47.2
47.9
32.8
37.8
112.8
125.4
4.5
152.9
15.6
101.3
164.8
32.9
38.8
78.1
32.4
5.6
62.8
33.5
55.5
20.0
39.1
8.0
421.4
6.1
6.5
84.2
55.4
6.2
65.5
128.5
8.6
18.9
38.2
78.7
93.4
16.6
0.7
122.9
10.4
59.4
751.7
0.2
54.8
53.9
35.2
42.3
121.5
136.5
5.2
180.6
17.8
118.2
188.8
38.5
45.6
83.6
35.1
6.1
67.3
35.4
59.7
21.3
41.4
8.5
451.3
6.3
6.8
92.1
58.7
6.5
70.9
141.6
9.2
20.7
41.0
84.3
100.5
17.8
0.6
131.1
11.2
64.4
823.0
0.2
59.5
57.7
36.7
45.3
126.2
142.7
5.7
198.7
19.2
129.3
203.9
42.3
50.1
39.0
30.7
1.4
32.3
17.7
26.1
10.5
20.2
3.5
211.8
2.7
1.7
35.8
29.5
3.3
22.2
50.2
2.3
9.0
15.6
41.0
49.2
8.0
0.2
61.8
5.0
28.5
330.0
0.0a
26.7
27.1
21.2
21.6
31.2
75.1
2.5
77.0
8.3
51.6
90.2
15.1
18.6
44.3
17.5
1.7
36.7
19.7
29.8
11.8
22.7
4.0
239.8
3.3
1.9
42.2
33.1
3.7
26.3
60.9
2.6
10.4
17.9
48.2
56.3
9.4
0.2
71.2
5.7
33.0
392.4
0.0a
30.8
31.0
23.0
24.4
34.8
83.7
2.9
92.0
9.6
61.1
104.1
17.8
22.2
50.4
20.1
2.0
41.3
22.1
33.8
13.1
25.3
4.5
270.1
4.0
2.1
49.0
36.7
4.0
30.7
73.5
2.9
12.2
20.4
55.3
63.9
10.6
0.2
80.8
6.5
37.9
462.6
0.0a
36.0
35.0
24.7
27.0
37.8
91.9
3.4
109.2
11.0
71.6
119.9
20.9
26.2
57.1
23.3
2.3
46.8
24.5
38.7
14.7
28.2
5.1
306.4
4.2
2.3
57.9
40.9
4.4
35.5
87.8
3.2
14.5
23.3
62.7
73.0
12.0
0.2
91.0
7.5
43.9
546.5
0.0a
42.0
39.7
26.7
30.8
40.5
99.6
3.9
130.2
12.7
84.5
138.2
24.8
31.1
13.4
876.9
927.9
950.9
958.8
369.3
398.6
413.3
420.4
13.0
1.9
15.0
17.0
10.5
I. 6
7.0
2.7
6.0
14.0
14.0
18.5
9.0
8.0
12.0
II. 5
4.7
22.5
22.5
79.6
0.2
162.6
201.9
51.7
1.3
8.5
1.5
3.8
15.4
72.7
6.5
31.1
28.1
19.1
134.0
1.3
13.4
44.1
87.0
0.2
162.2
214.2
56.3
1.4
10.6
1.7
4.0
17.8
71.4
7.2
36.4
32.3
19.2
139.5
1.4
15.3
49.8
88.1
0.2
160.1
216.6
60.8
1.4
12.8
1.7
4.1
20.2
67.2
7.9
41.9
35.4
18.5
138.6
1.4
17.0
56.9
86.0
0.2
160.1
215.3
63.6
1.4
14.1
1.8
4.1
21.4
64.4
8.3
45.3
36.8
18.0
137.3
1.4
17.8
61.5
35.8
0.0
80.7
92.7
18.0
0.2
2.2
0.2
0.9
6.4
32.7
3.5
10.4
9.3
7.7
32.2
0.3
8.3
27.7
40.5
0.0
81.6
101.2
19.6
0.2
2.8
0.3
1.0
7.5
33.1
4.0
12.2
11.0
7.9
34.7
0.3
9.6
31.1
42.9
0.0
79.8
104.1
21.3
0.2
3.5
0.3
1.0
8.6
31.4
4.4
14.2
12.4
7.7
34.7
0.3
10.9
35.5
41.0
0.0
79.7
103.0
23.0
0.2
4.2
0.3
1.0
9.7
29.0
4.8
16.4
13.2
7.3
34.2
0.3
11.9
41.1
6.2
1980-85 mortality,
percent of children
dying
Before
Before
agel
age 5
1985
Annual number of infant and child deaths
if 1980-85 mortality levels continue
(in thousands)
Infants
Age 1-4
1990
1995
2000
1985
1990
1995
2000
Asia (without China)
10.1
15.4
4,782.0
4,831.4
4,845.0
4,793.4
2,470.2
2,488.8
2,545.0
2,497.4
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
19.4
34.0
20.5
21.5
9.5
161.4
557.0
7.4
76.8
5.5
0.6
180.7
588.5
194.9
608.9
7.9
79.7
115.1
323.6
3.9
26.9
5.5
0.6
0.9
2,460.5
420.9
49.8
18.8
28.9
20.8
13.3
11.8
0.4
3.9
98.4
10.2
5.2
0.5
0.9
128.8
344.6
4.2
28.0
2.8
0.1
0.2
1,219.7
252.3
25.9
5.8
9.4
9.6
4.9
1.8
0.2
145.7
361.7
7.7
79.1
197.2
615.1
8.1
79.4
4.8
0.5
0.9
2,395.9
404.3
39.5
19.3
26.3
21.4
148.8
368.5
4.4
28.4
2.4
12.8
13.9
7.0
18.3
3.1
1.0
11.0
8.4
16.0
3.0
3.0
12.3
3.0
6.6
3.6
5.3
13.9
7.4
12.0
5.1
3.0
1.0
3.9
4.8
27.3
3.6
1.2
16.5
13.5
24.0
3.9
3.9
18.0
4.1
7.6
5.6
7.0
21.5
10.5
18.0
8.5
3.5
1.3
5.0
6.0
0.9
2,499.1
426.4
50.4
17.9
28.1
19.9
13.5
11.3
0.4
3.5
92.2
9.7
494.8
87.8
0.5
0.4
16.8
517.4
90.7
0.5
0.4
15.4
2,437.7
414.5
44.1
19.2
27.2
21.3
12.8
12.2
12.3
0.4
4.2
12.5
0.4
4.4
107.4
11.1
104.6
10.8
517.0
512.3
91.5
0.5
0.4
90.8
0.5
0.4
13.9
2.7
0.1
0.2
1,258.7
258.9
24.8
5.4
8.5
9.1
5.0
1.7
0.2
1.1
49.3
3.9
239.1
58.6
0.1
0.1
1.2
52.2
4.1
257.5
4.3
28.5
2.7
0.1
0.2
1,228.1
253.9
24.2
6.0
8.8
10.0
4.8
1.9
0.2
1.3
56.2
61.0
4.3
260.5
62.6
0.1
0.1
0.1
0.1
0.1
0.2
1,189.8
242.6
19.8
6.1
8.3
10.1
4.4
2.0
0.2
1.4
59.1
4.6
256.1
61.8
0.1
4.4
3.9
0.1
3.8
68.4
4.7
17.2
15.5
146.3
51.3
54.3
17.1
57.4
18.0
56.5
62.8
61.9
7.6
10.5
136.6
144.2
14.3
66.6
147.6
China
3.9
5.5
776.9
801.8
830.4
846.3
305.0
313.2
325.4
336.9
Latin America & Caribbean
6.3
8.8
770.8
806.8
830.2
841.9
298.3
317.1
329.9
340.7
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
3.6
4.2
12.4
19.5
26.3
44.7
9.5
2.8
26.4
38.0
289.7
6.4
44.3
26.2
42.1
7.1
2.3
5.0
2.0
1.7
7.5
7.0
7.0
7.0
3.6
12.8
26.2
34.2
282.0
6.2
291.3
291.2
6.4
44.3
4.3
18.3
95.3
4.4
20.5
99.4
4.4
25.3
100.4
1.3
21.0
0.3
0.5
4.0
8.1
6.2
1.3
22.1
0.3
0.6
4.2
15.6
0.2
15.7
7.6
0.4
55.1
5.1
0.7
17.2
0.2
17.7
8.0
0.4
57.4
5.7
0.7
2.7
33.3
0.2
0.1
0.2
4.7
4.3
22.7
100.4
1.3
22.3
0.3
0.6
4.2
9.8
7.5
18.9
0.2
19.9
9.0
0.4
58.6
6.2
0.7
2.9
34.3
0.2
0.1
0.2
4.9
8.2
2.1
5.3
7.6
2.6
4.5
9.9
1.7
2.4
3.0
3.9
7.5
2.4
2.0
9.5
9.5
10.0
12.0
4.5
19.0
12.5
2.7
7.5
11.5
3.7
6.5
14.5
1.9
2.8
3.4
4.7
43.0
1.5
2.9
14.8
23.3
15.1
23.2
0.9
34.3
14.7
1.3
135.5
10.7
1.5
0.9
38.5
15.9
1.3
139.8
11.8
1.6
1.6
3.3
15.1
27.6
18.3
27.8
0.8
43.1
18.2
46.1
20.0
1.2
141.5
12.8
141.5
13.3
1.6
3.3
14.9
28.6
19.5
29.2
0.8
1.2
1.6
6.8
22.4
1.6
6.6
73.2
1.2
0.7
1.7
23.2
9,745.3
287.1
10,295.9
287.4
10,803.3
286.0
11,054.0
0.6
10.0
43.1
0.6
10.6
0.6
11.1
43.2
10,583.2
11,089.3
5.8
68.6
1.2
0.7
1.7
21.2
Less Developed
More Developed
8.8
1.6
13.5
Sweden
Japan
United States
0.7
0.6
1.1
0.8
0.9
1.3
0.6
10.0
42.2
World Total
7.8
11.8
10,032.4
1.8
1.6
3.2
15.2
25.7
16.6
25.5
6.4
44.4
6.3
71.9
1.2
0.7
1.7
2.4
9.0
6.8
1.3
22.2
0.3
0.6
4.1
10.5
8.3
20.6
0.2
22.5
10.7
0.3
58.6
6.7
0.7
3.0
34.5
0.2
0.1
0.2
73.3
1.2
0.6
1.8
23.7
31.3
0.2
0.1
0.2
4,998.2
42.0
3
5,664.0
42.1
5,958.0
0.1
4.3
284.9
4.4
0.1
0.1
0.1
3.8
42.8
3.9
6.5
6.7
4.0
6.8
11,338.9
5,040.2
5,343.8
5,706.0
5.0
41.8
6.7
5,999.8
Notes appear on page 96
79
Table 3: Numbers of Infants and Children Age 1-4
if Mortality Levels are Reduced To Reach Year 2000 Goals (in Thousands)
tye 1-4
Infants
1985
1990
1995
2000
1985
1990
1995
2000
19,606.3
22,935.0
26,548.3
29,000.5
65,904.8
78,987.7
94,087.1
112,124.5
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
Zaire
Zambia
Zimbabwe
369.6
186.9
50.9
296.4
199.6
389.0
102.9
199.3
72.2
1,924.7
37.4
27.3
588.4
426.5
219.2
60.0
340.3
226.7
445.8
116.6
226.6
82.6
2,211.1
45.4
30.7
694.0
286.6
36.4
483.3
1,274.2
65.5
489.0
254.1
529.5
278.7
77.3
420.9
272.0
553.5
141.0
273.1
101.1
2,740.7
53.5
36.6
896.5
346.9
42.7
615.7
1,699.6
78.8
1,213.6
626.5
179.9
1,438.9
1,702.7
751.4
899.9
254.0
2,006.1
1,082.7
304.3
1,594.0
1,056.0
2,154.6
534.6
1,035.6
397.1
10,375.4
208.1
384.6
847.5
1,440.4
351.9
459.2
Near East
8,822.3
Africa
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
80
252.1
32.6
406.7
1,047.3
57.9
95.7
416.6
326.1
355.4
85.0
24.7
112.5
479.5
385.8
414.6
98.9
23.9
650.3
74.0
326.7
5,258.6
11.5
330.4
309.4
164.7
223.2
1,282.9
995.8
70.1
388.5
254.2
509.3
131.4
255.0
93.8
2,527.4
51.7
34.2
812.2
322.6
40.3
562.9
1,530.3
73.3
133.0
147.4
548.0
446.2
479.9
112.9
22.7
743.9
84.8
379.9
593.4
484.7
525.6
121.8
22.0
803.6
92.2
6,216.3
11.6
6,882.4
387.8
353.3
180.8
253.4
1,392.0
1,093.7
37.8
424.8
382.0
192.1
275.3
1,457.4
1,485.1
164.4
971.5
677.5
1,339.3
343.0
662.2
255.2
6,294.5
123.5
92.9
2,002.4
821.9
109.2
1,379.5
3,590.4
204.1
316.0
1,491.8
1,029.2
1,116.4
215.8
1,150.1
787.9
1.564.6
398.6
775.0
296.7
7,455.5
154.3
122.1
1,737.4
1,274.3
1,360.4
415.3
543.5
9,443.2
9,795.1
9,985.1
848.6
12.9
934.1
937.6
1,517.1
1,522.4
1,742.8
693.4
94.5
189.0
70.8
80.5
173.6
696.7
57.8
525.9
527.2
952.7
11.5
1,514.8
1,778.2
755.3
96.7
229.2
74.8
83.8
198.1
660.8
63.7
610.4
581.3
206.7
1,430.2
4,389.6
10.9
281.5
268.6
149.0
195.7
1,158.6
888.4
27.7
1,034.2
123.1
711.7
1,238.4
297.1
1,622.5
633.4
93.1
151.1
64.0
76.4
149.1
704.7
50.9
446.6
455.9
210.4
1,364.0
34.0
90.4
297.4
32.5
1,246.6
142.9
12.1
212.8
1,429.3
34.9
104.6
340.8
997.7
1,664.0
415.7
11.6
1,156.4
41.3
11.3
1,528.2
1,787.3
795.3
97.6
254.2
75.6
84.3
212.3
35.3
638.6
67.9
664.7
607.1
203.1
1,429.5
36.7
117.9
124.4
393.7
429.3
897.0
343.8
8,777.2
192.9
2,887.2
1,652.5
179.0
1,103.8
1,815.8
459.7
601.9
63.8
461.3
107.0
337.2
97.5
2,185.9
256.2
1,097.5
17,927.8
45.2
1,109.7
1,051.1
555.8
757.8
4,756.8
3,500.1
110.1
4,233.6
499.1
2,906.3
4,993.7
279.1
916.9
1,829.4
2,421.6
970.0
125.9
1,679.5
4,436.8
234.7
378.4
279.8
99.2
1,814.4
215.8
911.8
14,617.3
42.0
930.8
886.0
480.8
641.0
4,209.3
3,039.3
91.9
3.436.2
420.4
2,382.3
4,209.6
1,025.9
1,330.4
559.5
1,350.5
1,126.4
142.8
2,016.6
5,469.8
268.0
453.9
2,016.7
1,539.1
1,638.6
395.3
92.8
2,590.7
303.0
1,311.8
21,886.6
46.6
1,337.1
1,232.5
633.2
878.5
5,259.9
3,993.1
138.9
3,495.3
1,312.2
161.9
2,398.3
6,674.0
307.3
559.6
2,341.8
1,830.8
1,980.7
462.4
87.7
3,042.3
358.4
1,575.8
26,754.6
46.2
1,612.9
1,448.8
724.0
1,042.3
1,235.4
1.483.6
1,616.1
1,947.5
5,730.3
4,491.8
157.1
6,423.9
696.7
4,292.4
7,063.3
1,800.8
2,363.5
31,934.7
35,378.2
37,573.0
39,081.9
3,014.9
53.2
5,607.5
5,720.0
2,326.9
370.8
526.3
240.8
294.1
517.2
2,628.6
173.0
1,591.9
1,637.3
787.1
5.024.3
130.8
298.4
991.8
3,488.3
49.9
3,767.5
46.5
5,822.0
6,833.1
2,844.9
384.2
834.1
296.6
3,676.2
45.2
5,958.7
6,960.1
3,132.1
389.8
1,008.5
332.1
726.7
334.9
830.0
2,496.2
264.1
2,628.1
2,404.8
797.4
5,605.7
5,816.7
6,440.1
2,576.9
371.9
670.5
271.0
308.8
615.0
2,721.1
205.4
1,901.3
1,951.5
831.2
5,510.7
139.9
354.8
1,153.1
130.5
5,207.5
589.2
3,518.9
5,942.2
2,642.1
231.9
2,245.4
2,220.2
821.0
5,605.9
136.2
419.6
1,363.2
301.7
146.0
472.3
1,630.0
Age 1-4
Infants
1985
1990
1995
2000
1985
1990
1995
2000
Asia (without China)
43,953.1
44,733.7
45,166.2
45,084.7
162,899.0
167,521.3
174,903.1
175,699.4
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
726.3
3,977.3
48.3
1,039.0
26.4
19.6
90.3
21,017.3
4,753.1
282.0
586.8
923.7
149.2
438.2
834.8
4,249.5
923.8
4,441.5
53.5
1,092.4
26.0
16.8
92.7
20,896.1
4,685.1
255.9
634.4
900.8
954.9
4,519.1
54.7
1,096.9
24.7
16.5
89.8
20,755.8
4,608.2
232.2
642.3
874.4
166.8
399.6
184.9
11.8
2,233.7
13,837.7
166.9
3,929.7
89.8
79.6
345.8
78,494.9
18,050.6
977.0
2,247.8
3,498.2
2,694.4
15,175.4
184.6
4,158.8
98.2
77.4
379.3
78,307.2
17,996.7
3,588.0
17,190.0
42.3
411.9
1,271.5
1,703.4
42.8
380.0
1,259.1
1,809.3
17.0
41.4
354.1
728.7
144.1
4,074.2
1,751.6
16.8
39.9
347.2
3,276.5
16,394.7
196.1
4,295.1
100.9
68.3
381.0
81,148.0
18,515.8
1,035.3
2,505.4
3,684.9
623.4
1,712.5
695.6
46.5
298.2
2,553.4
529.1
15,609.9
6,939.5
68.8
1,361.3
1,865.8
China
19,096.9
19,795.5
Latin America & Caribbean
11,696.4
705.8
252.0
3,780.8
262.1
825.9
74.9
171.9
187.9
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
Less Developed
More Developed
Sweden
Japan
United States
World Total
163.6
11.6
64.0
604.2
123.3
3,796.9
1,665.4
17.4
317.8
204.5
312.8
24.6
245.6
170.1
62.1
2,447.6
131.9
57.9
123.5
650.0
72.3
28.6
56.3
529.5
103,175.1
17,652.4
51.4
1,077.2
27.2
18.3
94.9
20,909.2
4,722.3
283.7
619.0
953.3
158.4
431.2
171.6
11.7
71.2
653.1
130.4
4,027.7
1,728.9
164.1
415.6
179.7
93.3
65.8
358.7
80,849.2
18,079.6
880.8
2,560.6
3,485.9
649.2
1,592.9
731.9
2,293.9
490.5
14,920.5
6,670.2
69.8
171.9
170.7
1,406.2
1,863.0
1,750.7
625.9
45.0
237.5
2,093.8
462.1
13,395.1
6,318.5
69.1
166.9
1,688.1
5,215.8
6,347.3
1,579.4
4,745.7
6,833.5
1,434.8
5.272.1
7,346.5
317.9
2,769.7
568.1
15,854.1
6,942.8
66.8
159.5
1,381.9
5,588.1
7,338.0
20,597.6
21,091.1
74,085.0
76,722.1
80,382.6
83,918.5
12,256.7
12,606.8
12,813.2
44,104.0
47,150.9
49,104.2
50,626.1
713.4
284.9
3,908.9
271.8
855.5
78.1
188.8
194.6
351.9
226.3
345.9
23.5
278.9
185.2
60.6
2,539.2
146.8
60.9
134.6
685.5
74.0
28.6
56.7
562.0
712.1
318.7
3,956.6
272.9
862.2
79.0
194.5
194.7
381.4
716.7
342.5
2,769.2
2,849.9
998.9
2,827.0
3,985.1
271.6
14,303.6
1,017.6
3,143.1
289.5
646.7
709.5
15,141.3
15,518.1
1,095.2
3,406.8
314.6
781.8
772.4
1,451.7
936.6
2,854.8
1,331.1
15,734.4
1,083.5
3,432.1
316.7
17.4
109,164.1
17,702.6
11.8
77.4
703.4
138.8
4,063.2
1,753.8
251.4
379.7
22.4
315.7
213.1
57.3
2,583.7
159.8
62.3
142.8
703.1
73.4
27.5
57.2
585.4
114,714.1
17,654.4
80.1
865.2
79.3
193.4
193.4
398.2
268.8
401.3
22.0
340.1
236.4
55.8
2,599.6
167.4
62.5
147.3
711.0
72.5
26.7
1,163.8
749.9
1,129.1
99.7
841.0
626.3
247.4
9,352.7
474.6
222.9
460.7
2,350.7
282.5
1,076.4
3,342.8
309.7
732.4
755.3
1,313.0
836.5
1,269.9
95.9
969.4
669.9
249.2
9,862.3
541.8
238.0
513.7
1,151.2
1,420.2
91.2
1,116.3
763.6
233.6
10,192.0
602.8
247.7
552.7
47.1
772.3
762.9
1,572.2
1,060.8
1,581.5
87.4
1,295.4
928.7
222.7
10,310.5
658.7
249.4
585.2
2,775.5
289.6
57.6
598.9
223.3
2,025.7
117,974.6
17,628.2
378,927.5
70,260.1
405,760.3
70,782.5
436,049.9
70,698.7
461,450.4
378.5
6,202.8
14,647.9
334.4
5,952.6
15,098.4
332.8
6,239.7
15,343.2
325.9
6,797.5
15,109.5
449,187.6
476,542.8
506,748.6
531,867.2
3,719.1
3,811.2
81.5
1,701.1
3,781.4
120,827.5
126,866.7
132,368.5
135,602.8
82.5
1,623.6
861.7
46.1
266.5
2,564.6
295.8
116.1
225.2
2,182.9
83.4
1,527.9
3,802.8
89.5
1,527.9
531.6
1,064.0
2,426.3
3,905.4
578.6
1,727.2
659.8
207.9
4,331.3
112.5
2,702.1
296.4
112.5
227.1
2,290.6
106.5
229.9
2,384.4
70,416.8
81
Table 4: Year 2000 Goals for Reduced Infant and Child Mortality,
and Numbers of Children Dying Before Age 1 and Age 5
if Mortality Levels are Reduced
Annual number of infant and child deaths
if mortality levels are reduced
(in thousands)
Year 2000 mortality
goals, percent of
children dying
Before
age 1
Before
age 5
Africa
5.6
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
Zaire
Zambia
Zimbabwe
Age 1-4
Infants
2000
1985
1990
1995
2000
1985
1990
1995
7.4
2,538.8
2,470.1
2,299.7
1,917.5
1,555.4
1,407.5
1,162.9
790.3
7.5
5.0
3.8
7.5
5.0
5.0
7.5
7.5
4.1
7.5
5.0
7.5
4.9
7.5
7.5
5.0
4.0
5.0
7.5
3.3
7.5
7.5
7.5
1.4
7.5
5.0
7.5
5.0
0.7
7.5
7.5
7.5
7.5
4.2
5.0
7.5
5.0
5.0
5.0
5.0
4.4
4.0
10.5
6.5
4.8
10.5
6.5
6.5
10.5
10.5
5.1
10.5
6.5
10.5
6.3
10.5
10.5
6.5
5.1
6.5
10.5
4.1
10.5
10.5
10.5
1.6
10.5
6.5
10.5
6.5
0.8
10.5
10.5
10.5
10.5
5.2
6.5
10.5
6.5
6.5
6.5
6.5
5.6
5.1
60.9
24.4
4.1
49.5
27.0
43.1
16.1
31.4
6.2
332.0
4.5
5.4
61.9
44.8
5.1
48.2
89.2
6.9
13.9
29.4
59.7
72.4
12.8
0.7
95.6
8.0
45.0
542.1
0.1
40.7
42.2
30.3
33.8
102.5
113.4
3.9
128.4
13.5
86.0
143.0
27.9
32.7
59.1
23.3
4.1
47.6
24.9
41.5
15.5
30.3
6.0
318.1
4.5
4.9
61.8
42.3
4.9
47.6
91.9
6.5
14.1
28.7
58.3
68.4
12.8
0.6
92.8
7.6
44.5
535.6
0.1
41.2
41.2
27.2
32.1
96.2
104.2
4.0
127.5
13.2
84.8
138.9
28.0
33.1
55.3
21.3
3.9
44.3
21.7
38.7
14.5
28.2
5.6
293.6
4.1
4.3
59.4
38.1
4.4
44.5
90.7
5.8
14.0
27.0
53.6
61.4
12.2
0.5
85.9
6.9
42.5
503.1
0.1
40.9
38.9
23.1
29.4
85.8
90.3
3.9
120.6
12.4
79.7
129.5
27.2
32.2
47.1
17.0
3.4
37.5
16.7
32.6
12.4
24.1
4.8
246.0
3.2
3.4
51.5
31.3
3.8
36.8
79.1
4.7
12.8
22.9
44.0
48.9
10.7
0.4
72.0
5.6
36.8
414.8
0.1
36.9
33.7
17.9
24.7
70.5
70.2
3.6
99.7
10.5
66.2
107.8
23.6
28.0
39.0
30.7
1.4
32.3
17.7
26.1
10.5
20.2
3.5
211.8
2.7
1.7
35.8
29.5
3.3
22.2
50.2
2.3
9.0
15.6
41.0
49.2
8.0
0.2
61.8
5.0
28.5
330.0
0.0a
26.7
27.1
21.2
21.6
31.2
75.1
2.5
77.0
8.3
51.6
90.2
15.1
18.6
35.7
13.5
1.4
29.4
15.2
23.3
9.5
18.3
3.1
192.6
2.6
1.6
33.1
26.5
3.0
21.0
47.2
2.1
8.4
13.8
38.3
44.7
7.6
0.1
57.1
4.5
26.6
305.0
0.0a
24.9
25.0
18.3
19.6
28.8
64.7
2.4
71.5
7.5
47.6
81.0
13.9
17.2
30.1
10.9
1.2
24.5
11.8
18.8
7.9
15.3
2.5
160.6
2.2
1.5
27.4
21.5
2.4
18.0
40.0
I. 9
7.4
11.0
31.8
36.4
6.5
0.1
47.8
3.5
22.8
251.6
0.0a
22.0
21.1
14.1
16.1
24.6
49.2
2.1
59.5
6.1
39.2
65.6
II. 5
14.3
21.8
6.8
1.0
17.5
6.9
12.5
5.7
11.1
1.6
114.4
1.3
1.3
18.9
14.8
1.7
13.0
27.1
I. 5
5.9
7.0
21.4
24.0
4.9
0.1
33.7
2.2
17.0
164.3
0.0a
16.9
15.5
8.8
II. 5
19.0
28.6
1.6
39.3
4.1
25.9
42.5
7.9
9.6
Near East
4.5
5.8
876.9
788.2
664.9
526.7
369.3
322.0
251.4
168.9
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
4.4
0.8
5.0
5.0
3.9
0.7
2.7
1.2
2.4
4.8
4.8
5.0
3.3
2.9
4.3
4.6
1.9
7.5
7.5
5.5
0.9
6.5
6.5
4.8
0.8
3.2
1.3
2.8
6.2
6.2
6.5
4.0
3.5
5.4
5.8
2.2
10.5
10.5
79.6
0.2
162.6
201.9
51.7
1.3
8.5
1.5
3.8
15.4
72.7
6.5
31.1
28.1
19.1
134.0
1.3
13.4
44.1
74.2
0.2
138.3
178.6
48.0
1.2
9.1
1.4
3.4
15.2
60.9
6.0
31.0
27.6
16.4
119.0
1.2
13.3
43.3
62.2
0.1
113.0
144.6
42.9
1.0
9.0
1.2
2.9
14.2
47.4
5.2
29.6
25.0
13.1
97.8
1.0
12.6
42.0
48.0
0.1
89.4
107.9
35.5
0.8
7.9
1.0
2.3
12.0
36.0
4.1
25.3
20.5
10.1
76.7
0.8
10.8
37.4
35.8
0.0a
80.7
92.7
18.0
0.2
2.2
0.2
0.9
6.4
32.7
3.5
10.4
9.3
7.7
32.2
0.3
8.3
27.7
32.2
0.0a
65.6
80.8
15.9
0.1
2.3
0.2
0.8
6.0
26.6
3.1
9.7
8.7
6.4
30.2
0.3
7.8
25.3
24.9
0.0a
47.9
61.2
13.2
0.1
2.1
0.2
0.6
5.2
18.9
2.4
8.3
7.2
4.7
25.6
0.2
6.7
21.9
14.9
0.0a
31.2
37.8
9.8
0.1
1.6
0.2
0.4
3.8
11.4
1.6
6.1
4.8
3.0
20.4
0.1
4.9
16.9
82
Annual number of infant and child deaths
if mortality levels are reduced
(in thousands)
Year 2000 mortality
goals, percent of
children dying
Before
agel
Before
age 5
Infants
Age 1-4
1985
1990
1995
2000
1985
1990
1995
2000
Asia (without China)
4.8
6.3
4,782.0
4,083.4
3,346.0
2,570.2
2,470.2
1,988.1
1,499.5
927.2
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
7.5
7.5
7.5
3.5
7.5
1.5
0.5
5.0
4.2
7.5
1.5
1.5
5.0
1.5
3.3
1.8
2.7
7.5
3.7
5.0
2.5
1.5
0.5
2.0
2.4
3.8
10.5
10.5
10.5
4.3
10.5
1.7
0.6
6.5
5.3
10.5
1.7
1.7
6.5
1.7
4.0
2.1
3.1
10.5
4.6
6.5
3.0
1.7
0.6
2.3
2.8
4.7
161.4
557.0
7.4
76.8
5.5
0.6
0.9
2,499.1
426.4
50.4
17.9
28.1
19.9
13.5
11.3
0.4
3.5
92.2
9.7
494.8
87.8
0.5
0.4
16.8
62.8
136.6
148.1
516.7
6.7
67.5
4.6
0.5
0.8
2,065.1
359.0
42.0
16.0
24.7
17.2
11.3
10.1
0.4
3.3
85.1
8.7
428.6
77.3
0.5
0.4
13.1
52.8
123.0
124.7
460.3
5.8
56.2
3.4
0.4
0.6
1,654.1
292.6
30.3
13.5
19.2
13.9
9.0
8.7
0.3
3.0
76.3
7.6
339.6
64.6
0.4
0.3
10.1
47.0
104.2
90.5
389.9
4.8
44.4
2.3
0.3
0.5
1,240.6
226.0
21.0
10.8
14.7
10.2
6.8
7.0
0.2
2.4
63.9
6.2
248.6
50.8
0.3
0.2
7.8
38.2
81.7
115.1
323.6
3.9
26.9
2.7
0.1
0.2
1,258.7
258.9
24.8
5.4
8.5
9.1
5.0
1.7
0.2
1.1
49.3
3.9
239.1
58.6
0.1
0.1
4.7
17.2
51.3
101.8
285.1
3.5
22.5
2.3
0.1
0.2
973.2
195.5
21.5
4.5
7.2
7.6
3.7
1.6
0.2
1.0
43.3
3.2
204.2
45.9
0.1
0.1
3.4
12.5
43.9
81.6
234.3
2.8
17.1
1.7
0.1
0.1
721.2
137.9
15.6
3.2
4.7
5.8
2.5
1.5
0.1
0.8
36.6
2.5
149.9
31.3
0.1
0.1
2.3
10.3
35.2
46.0
170.1
2.1
11.1
1.0
0.1
437.6
74.0
8.9
1.9
2.5
3.6
1.2
1.4
0.1
0.5
27.5
1.7
89.0
15.1
0.0a
0.0a
1.4
7.1
23.2
China
2.0
2.3
776.9
683.9
586.2
472.9
305.0
239.5
171.2
96.0
Latin America & Caribbean
3.2
3.9
770.8
688.1
585.8
470.1
298.3
252.1
193.1
126.1
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
1.8
5.0
3.5
1.2
2.5
1.0
0.8
3.7
3.5
3.5
3.5
1.8
7.5
4.1
1.1
2.7
3.8
1.3
2.3
4.9
0.8
1.2
1.5
1.9
2.1
6.5
4.3
1.4
3.0
1.1
0.9
4.6
4.2
4.3
4.3
2.1
10.5
5.1
1.2
3.1
4.8
1.5
2.6
6.4
0.9
1.4
1.7
2.2
26.2
34.2
282.0
6.2
43.0
1.5
2.9
14.8
23.3
15.1
23.2
0.9
34.3
14.7
1.3
135.5
10.7
1.5
5.8
68.6
1.2
0.7
1.7
21.2
22.5
31.3
247.1
5.5
37.8
1.4
2.7
13.0
21.9
14.2
21.8
0.7
33.8
13.6
1.1
119.3
10.1
1.4
5.3
61.3
1.1
0.6
1.5
19.1
18.5
27.3
205.6
4.5
31.4
1.1
2.3
10.7
19.5
12.9
19.7
0.6
32.7
12.8
0.9
99.9
9.0
1.1
4.7
51.6
0.9
0.5
1.2
16.4
14.7
21.1
162.7
3.6
24.8
0.9
1.8
8.3
16.0
10.9
16.3
0.5
29.3
11.2
0.7
79.1
7.4
0.9
3.8
41.0
0.7
0.4
1.0
13.2
4.3
18.3
95.3
1.3
21.0
0.3
0.5
4.0
8.1
6.2
15.6
0.2
15.7
7.6
0.4
55.1
5.1
0.7
2.4
31.3
0.2
0.1
0.2
4.4
3.8
16.0
80.0
1.1
17.0
0.2
0.5
3.5
7.2
5.3
13.0
0.2
15.1
6.3
0.3
44.5
4.5
0.5
2.1
26.8
0.1
0.1
0.2
3.8
3.1
12.6
60.7
0.9
11.8
0.2
0.4
2.8
5.9
4.3
9.6
0.1
13.9
5.0
0.2
32.1
3.5
0.4
1.5
20.7
0.1
0.1
0.2
3.0
2.4
8.0
40.1
0.6
6.5
0.1
0.2
2.0
4.1
2.9
5.3
0.1
12.2
3.6
0.1
18.5
2.3
0.2
0.9
13.5
0.1
0.1
0.1
2.2
Less Developed
More Developed
4.3
0.8
5.6
0.9
9,745.3
287.1
8,713.6
245.1
7,482.6
201.9
5,957.4
159.2
4,998.2
42.0
4,209.3
35.1
3,278.1
27.8
2,108.6
20.5
Sweden
Japan
United States
0.5
0.5
0.6
0.6
0.6
0.7
0.6
10.0
42.2
0.5
9.3
36.8
0.5
9.2
30.5
0.4
8.8
23.9
0.1
3.9
6.5
0.1
3.1
5.9
0.1
2.5
5.1
0.1
2.0
4.1
World Total
3.9
5.0
10,032.4
8,958.7
7,684.5
6,116.7
5,040.2
4,244.3
3,305.9
2,129.1
Notes appear on page 96
o.oa
83
Table 5: Country Populations and Basic Demographic Indicators
Total
population
(in thousands)
1985
Africa
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
Zaire
Zambia
Zimbabwe
Near East
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab. Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
84
Number of
years until
population
doubles
Percent
urban
1985
Crude
birth
rate
1985
Crude
death
rate
1985
Life expectancy
at birth
1960
1985
451,811.3
23
26
48
17
40
49
8,753.6
4,049.8
1,107.2
6,941.6
4,721.3
9,873.2
2,576.0
5,018.2
1,740.0
43,556.6
1,150.8
642.9
13,587.6
6,075.4
889.5
9,809.7
20,599.6
1,519.6
2,190.6
10,011.6
6,944.0
8,082.3
1,888.0
1,050.1
13,960.8
1,550.1
6,115.1
95,198.4
530.9
6,069.6
6,443.6
3,601.8
4,652.7
32,392.2
21,550.2
649.6
22,499.4
2,960.2
15,477.2
29,937.8
6,665.7
8,777.5
27
23
18
28
24
25
30
29
26
26
39
34
21
29
35
20
17
27
22
24
22
24
23
39
25
24
24
20
59
21
26
37
28
28
24
23
19
23
20
23
21
20
25
35
19
8
8
42
42
27
39
12
41
20
32
22
27
42
20
17
40
22
12
18
35
42
19
51
16
23
60
6
36
28
34
56
21
26
22
22
10
37
49
25
47
51
49
48
46
43
44
44
44
50
36
48
47
47
41
45
55
41
48
44
53
50
50
24
45
45
51
50
21
51
46
47
48
38
45
47
50
45
50
45
48
47
21
20
12
19
18
15
21
21
18
23
18
28
14
23
21
15
13
16
16
16
21
22
20
6
19
17
22
16
5
18
20
29
23
13
16
16
15
15
16
15
14
12
33
35
45
35
42
40
37
35
38
36
41
31
45
33
36
39
42
40
40
41
38
35
36
59
40
41
35
40
56
42
37
30
36
44
39
42
41
39
43
42
42
45
43
45
55
46
48
52
44
44
48
41
50
36
53
41
44
52
54
50
50
51
46
43
45
67
46
49
44
50
70
48
44
35
41
54
49
50
52
52
50
51
52
57
257,589.0
26
51
37
10
48
61
21,718.4
668.8
46,909.4
44,631.7
15,897.8
4,251.8
3,515.0
1,811.3
2,667.7
3,605.1
21,940.8
1,242.3
11,542.2
10,504.6
7,080.5
49,289.3
1,327.0
2,136.8
6,848.5
22
62
29
25
20
40
18
14
66
18
29
18
17
19
33
34
15
24
25
43
49
46
52
71
90
64
94
80
64
45
9
72
49
57
46
78
40
20
42
20
35
40
43
22
46
37
29
45
34
46
41
46
32
30
27
47
48
10
8
11
11
8
7
7
3
8
10
10
13
8
8
9
9
4
17
17
47
69
46
50
48
69
47
60
60
47
47
40
44
50
48
51
53
37
37
61
74
59
58
63
75
65
72
66
60
60
54
62
64
62
63
68
50
50
Percent
urban
1985
Crude
birth
rate
1985
Crude
death
rate
1985
35
27
32
12
45
57
51,411.3
59,712.8
26
26
34
36
29
40
38
38
38
27
29
43
30
30
28
38
25
30
28
26
30
44
62
42
38
35
19
12
5
24
12
41
92
26
25
11
64
65
16
38
20
45
51
8
14
30
40
36
100
21
20
20
48
43
38
30
46
29
17
30
30
43
30
23
39
29
36
33
35
41
37
42
32
36
17
26
26
30
26
17
17
10
22
5
6
12
12
18
6
6
15
6
11
6
8
18
13
15
8
5
6
6
8
10
33
40
38
44
34
59
65
44
41
42
54
54
44
54
45
51
52
38
41
43
53
60
64
62
52
44
38
49
47
59
41
70
76
57
55
46
69
69
51
68
57
69
63
47
53
51
63
70
72
69
63
60
China
1,059,521.0
57
21
19
7
47
69
Latin America & Caribbean
402,063.4
31
69
31
8
56
65
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
30,563.8
6,370.6
135,564.4
12,038.1
953.4
6,585.3
4,372.5
2,336.5
78,995.6
3,272.1
2,180.5
3,681.5
19,697.6
3,450.5
1,184.8
3,012.2
17,316.7
46
25
32
45
33
27
87
31
24
23
24
38
27
21
47
28
21
33
24
27
47
44
95
25
85
48
73
84
67
50
72
56
52
39
40
32
27
40
54
70
57
52
44
67
71
64
85
87
24
43
30
22
30
30
18
32
36
39
42
27
41
42
27
33
43
27
35
36
21
25
19
32
9
15
8
7
8
4
7
8
8
8
10
6
13
9
6
7
9
5
7
10
7
7
10
5
65
43
55
57
55
62
63
51
53
50
46
60
42
46
63
57
47
61
56
48
69
64
68
60
70
52
64
70
64
73
74
64
65
66
60
69
54
61
73
66
62
72
66
60
74
69
71
69
3,662,834.9
1,173,810.5
35
111
31
71
30
15
10
10
46
69
60
74
Sweden
Japan
United States
8,351.5
120,741.8
238,020.1
118
80
83
76
74
11
13
16
12
7
9
73
68
70
77
77
75
World Total
4,836,645.4
42
41
27
10
53
64
Asia (without China)
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
Less Developed
More Developed
Total
population
1985
Number of
years until
population
doubles
1,489,397.3
16,518.7
101,146.6
1,417.2
37,152.6
659.0
691.1
5,547.8
758,927.3
166,440.1
7,284.3
20,385.1
41,257.9
4,116.9
15,557.2
4,767.0
358.0
1,907.8
16,482.3
3,511.1
100,380.3
54,497.5
503.9
2,558.7
16,205.2
28,713.7
2,599.5
10,037.8
6,242.7
9,378.0
5,552.4
7,963.4
a
Life expectancy
at birth
1960
1985
Notes appear on page 96
85
Table 6: Women of Reproductive Age, Fertility Rates, and Births
1985
Projected number of women
of reproductive age (15-49)
______ (in thousands)______
1990
1995
2000
Total fertility
rate_
1960
1985
Projected number of births
during 5-year periods
_____ (in thousands)
1985-89
1990-94
1995-99
101,200.6
117,569.5
137,429.9
161,754.7
6.5
6.6
116,398.3
133,833.2
152,281.2
2,275.7
1,045.8
300.0
1,807.9
1,213.4
2,554.0
674.4
1,308.2
454.7
11,353.5
296.0
166.7
3,544.3
1,595.4
232.9
2,481.4
5,223.9
410.5
554.0
2,594.0
1,884.1
2,134.0
485.5
315.6
3,656.3
403.9
1,558.9
24,581.1
168.3
1,565.9
1,685.8
943.4
1,157.7
8,674.2
5,580.6
168.5
5,846.3
775.7
4,018.3
7,875.5
1,719.8
2,283.2
2,615.5
1,225.7
3,008.9
1,442.8
428.6
2,365.4
1,644.1
3,467.9
874.00
1,689.5
2,454.9
567.7
340.2
4,183.0
467.4
1,831.6
29,241.3
179.6
1,846.4
1,938.3
1,037.1
1,319.7
9,852.8
6,498.9
197.5
6,994.0
902.2
4,784.4
9,164.9
2,044.5
2,738.2
6.7
6.2
6.8
6.1
6.9
6.0
6.6
6.6
6.4
7.0
6.5
6.5
6.4
5.8
5.9
5.9
6.0
6.7
4.8
6.4
6.5
6.2
5.4
6.6
8.1
5.8
6.9
6.1
7.0
6.7
6.9
2.6
6.1
6.1
7.1
7.1
2.2
7.4
6.5
6.1
6.6
5.0
6.5
6.5
7.1
6.1
6.9
6.1
6.8
6.6
2,213.1
1,108.7
297.7
1,773.2
1,162.2
2,256.1
607.3
I, 181.0
414.5
II, 544.4
226.2
163.7
3,475.0
1,509.7
191.4
2,426.8
6,236.4
334.9
573.0
2,381.9
2,009.8
2,185.8
511.1
124.8
3,385.2
375.6
1,684.2
26,323.3
57.4
1,680.3
1,603.8
887.8
1,171.8
6,554.9
5,134.2
2,510.7
1,276.9
344.8
14,994.8
349.2
209.2
4,998.4
2,049.3
294.8
3,491.0
8,048.1
533.3
787.5
3,495.8
2,524.5
2.849.6
669.4
363.6
4,794.0
545.1
2,145.6
35,022.9
186.9
2,217.1
2,233.8
1,150.7
1,521.7
11,288.1
7,583.4
233.3
8,405.9
1,058.5
5,726.5
10,711.7
2,446.5
3,302.1
6.4
6.8
6.3
6.5
5.5
5.7
5.6
6.0
5.8
6.7
4.1
6.3
6.4
6.4
5.1
6.6
8.2
5.8
6.2
5.8
6.9
6.4
6.8
5.9
5.6
6.0
7.0
6.8
5.8
6.7
6.7
Zaire
Zambia
Zimbabwe
1,997.0
903.0
256.3
1,593.8
1,068.6
2,232.7
602.0
1,165.2
398.8
9,968.6
277.9
151.3
3,015.4
1,423.5
210.5
2,086.5
4,238.8
364.5
477.0
2,263.8
1,610.9
1,869.0
418.8
295.0
3,216.8
352.1
1,340.8
20,779.0
153.5
1,324.2
1,476.1
867.2
1,047.4
7,633.7
4,847.9
145.1
4,899.9
672.7
3,382.5
6,797.6
1,458.0
1,917.4
6,222.4
720.2
4,249.9
7,259.5
1,747.1
2,266.4
7,507.8
372.6
667.7
2,715.8
2,300.8
2,478.9
578.1
118.1
3,833.2
428.1
1,934.1
30,986.3
58.8
1,962.3
1,809.8
952.8
1,301.5
7,113.9
5,628.1
191.1
7,379.9
825.2
4,971.9
8,356.6
2,049.7
2,671.7
2,814.0
1.460.2
400.4
2,237.1
1,425.6
2,895.9
749.0
1,450.9
525.3
14,571.9
280.2
194.8
4,686.3
1,845.0
226.8
3,223.1
8,823.3
412.5
782.6
3,063.8
2,578.4
2,798.5
647.1
111.6
4,272.5
483.0
2,209.1
36,039.9
58.3
2,255.4
2,029.7
1,023.0
1,463.9
7,575.1
6,057.0
219.5
8,653.6
936.4
5,779.0
9,503.4
2,393.9
3,124.7
Near East
59,183.4
68,945.2
80,148.2
92,376.2
7.0
5.1
49,327.3
51,159.2
52,022.1
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
4,830.7
172.4
11,056.3
10,390.9
3,429.8
1,023.5
728.9
357.2
672.3
741.9
5,288.8
260.3
2,223.8
2,199.4
1,711.6
11,812.4
189.0
494.8
1,599.6
5,770.2
174.9
12,501.1
12,266.5
4,109.5
1,164.3
891.8
434.9
780.3
912.5
6,171.1
302.7
2,704.1
2,671.0
1,955.7
13,486.2
233.3
578.7
1,836.5
6,916.2
184.9
14,512.3
14,232.7
4,972.9
1,259.2
1,081.1
515.6
879.2
1,105.7
7,065.7
360.2
3,350.1
3,273.0
2,266.3
15,081.0
288.9
662.8
2,140.6
8,191.1
191.1
16,484.8
16,323.2
5,964.6
1,341.5
1,335.9
628.2
978.0
1,332.4
8,053.4
432.0
4,100.8
4,039.2
2,560.9
16,796.8
356.0
770.9
2,495.6
7.3
3.5
7.0
8.2
7.2
3.9
7.2
7.3
6.3
7.1
7.2
7.2
7.2
7.3
7.1
6.1
6.9
7.0
7.0
6.4
2.4
4.6
5.4
6.4
3.0
7.3
5.9
3.6
7.0
4.7
7.0
7.0
7.0
4.5
3.8
5.7
6.7
6.9
4,849.9
62.9
8,166.6
9,221.3
3,531.7
472.4
905.3
349.1
407.4
871.6
3,780.6
298.6
2,591.4
2,627.2
1,139.2
7,580.9
181.1
538.6
1,751.4
5,085.6
58.7
7.996.4
9,456.4
3,833.3
486.0
1,109.3
378.0
431.7
1,003.0
3,583.7
325.8
3,011.7
2,937.1
1,103.3
7,570.6
176.6
612.1
2,000.0
4,882.4
57.1
7,994.1
9,359.9
4,123.4
491.5
1,305.1
382.5
431.5
1,109.3
3,336.2
355.6
3,430.8
3,123.6
1,056.7
7,455.4
186.9
660.6
2,279.7
Africa
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Central African Republic
Chad
Congo
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Uganda
86
357.4
2,053.8
1,405.4
2,964.3
765.3
1,479.2
521.2
12,983.8
317.2
186.2
4,194.9
1,801.2
263.6
2,937.8
6,476.6
465.7
660.1
3,002.3
2,168.6
601.8
6.1
6.6
5.6
165.9
1,995.2
1,300.4
2,561.5
676.5
1,315.0
469.6
12,998.4
269.5
179.3
4,034.7
1,671.9
209.1
2,825.2
Projected number of women
of reproductive age (15-49)
_______ (in thousands)_______
Total fertility
rate
Projected number of births
during 5-year periods
______ (in thousands)
1985
1990
1995
2000
1960
1985
1985-89
1990-94
1995-99
Asia (without China)
356,607.9
403,529.6
452,753.3
503,370.2
6.0
4.2
236,493.9
239,908.3
235,435.8
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
3,809.7
21,937.8
328.6
9,152.0
173.5
179.0
1,420.9
179,925.0
41,244.8
2,059.2
5,102.7
11,072.9
947.7
3,951.1
1,096.6
80.8
452.5
3,659.3
794.3
22,559.3
13,435.7
110.0
754.1
4,180.1
13,283.8
14,896.6
4,831.2
25,880.9
366.4
10,512.7
189.8
191.4
1,548.8
202,394.5
46,707.0
2,227.9
5,842.7
11,984.5
1,089.1
4,508.7
1,248.0
91.4
524.6
4,165.3
910.3
25,498.5
15,377.5
122.5
795.0
4,547.8
15,100.8
16,872.7
5,349.9
30,344.1
407.7
11,730.1
183.5
207.3
1,672.4
225,763.1
51,981.2
2,163.9
6,624.4
12,880.3
1,247.7
5,044.7
1,415.0
102.1
604.3
4,750.3
1,036.0
29,448.9
17,617.6
137.2
819.2
4,956.8
16,685.8
19,579.9
5,939.8
35,316.7
453.2
12,854.3
210.0
225.0
1,730.5
249,042.6
57,339.1
2,459.6
7,420.0
13,753.6
1,429.3
5,632.7
1,600.7
112.3
694.7
5,392.8
1,172.5
34,342.4
19,765.6
152.3
815.9
5,387.3
18,231.3
21,896.3
6.9
6.7
6.0
6.0
6.4
6.3
5.0
5.9
5.5
6.3
5.7
5.7
5.6
6.8
6.2
6.3
5.7
5.8
6.2
7.1
6.8
7.4
5.4
5.3
6.4
6.7
6.8
5.8
5.4
3.9
5.6
3.3
1.9
4.0
3.8
4.9
3.8
2.6
5.6
3.6
5.1
4.8
5.0
6.0
5.5
5.6
4.2
5.3
1.7
3.1
3.1
4.0
4,455.8
22,540.1
276.1
5,613.6
153.0
98.4
478.5
111,426.0
24,924.2
1,607.1
3,133.8
5,000.1
835.9
2,223.3
882.9
60.1
355.6
3,446.0
669.7
21,478.1
8,884.3
89.6
216.8
2,034.5
6,281.8
9,328.9
4,992.3
23,587.5
283.8
5,701.7
147.9
87.1
477.4
111,834.6
24,975.2
1,485.7
3,213.5
4,693.6
868.0
2,179.5
920.2
60.1
391.7
3,702.6
710.1
21,676.4
9,086.1
87.8
213.8
1,844.6
6,883.0
9,804.4
5,088.1
23,989.8
290.5
5,670.7
131.4
83.8
451.2
108,655.7
23,962.4
1,235.0
3,260.5
4,438.7
874.1
2,029.0
954.2
60.3
411.2
3,870.8
746.5
21,343.9
8,979.2
85.1
200.7
1,770.5
7,198.3
9,653.9
China
275,991.0
312,160.8
333,656.6
346,036.1
5.6
2.2
100,382.0
104,223.0
107,558.0
Latin America & Caribbean
98,726.8
112,403.3
126,785.8
141,422.6
5.9
3.9
63,295.8
64,989.1
66,029.2
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
7,139.2
1,478.5
34,404.5
3,258.6
7,286.8
665.2
2,686.3
1,541.7
2,216.3
1,243.7
1,737.5
245.8
1,532.5
952.8
576.1
18,731.0
735.4
535.2
882.4
4,695.2
912.9
315.9
701.4
4,252.0
7,673.1
1,700.5
38,672.4
3,548.4
8,166.4
748.9
2,902.7
1,807.5
2,598.2
1,490.1
2,028.6
278.0
1,754.1
1,154.4
653.3
22,268.6
882.4
618.9
1,030.5
5,429.2
984.5
344.7
737.6
4,930.8
8,368.0
1,967.2
43,261.4
3,734.3
9,122.3
844.7
2,969.4
2,046.0
3,008.8
1,778.2
2,401.0
312.4
2,017.1
1,398.1
726.9
25,786.0
1,055.2
694.0
1,198.0
6,228.8
1,047.0
376.0
780.0
5,664.9
9,076.0
2,282.9
47,771.1
3,929.7
10,105.2
947.0
3,028.6
2,286.8
3,456.1
2,099.7
2,835.9
343.2
2,328.8
1,674.9
811.5
29,202.5
1,257.3
763.3
1,380.5
7,108.9
1,096.4
407.6
821.2
6,407.7
3.1
6.7
6.2
5.2
6.7
7.0
4.2
7.4
6.9
6.8
6.9
6.4
6.2
7.3
5.2
6.7
7.3
5.9
6.6
6.9
4.6
5.2
2.9
6.5
3.3
6.2
3.6
2.5
3.8
3.4
2.0
3.9
4.8
5.3
5.9
3.0
5.7
6.0
3.1
4.3
5.7
3.3
4.7
4.7
2.5
2.8
2.7
3.9
3,682.8
1,465.8
20,430.3
1,377.6
4,423.0
395.1
935.5
1,020.6
1,784.2
1,141.5
1,749.2
123.6
1,438.1
932.7
316.1
13,083.9
746.4
306.7
678.8
3,605.3
375.5
147.9
289.6
2,845.7
3,636.9
1,626.1
20,616.6
1,392.7
4,450.9
399.6
988.8
1,026.1
1,939.4
1,258.4
1,915.7
116.9
1,614.0
1,047.0
295.7
13,339.5
813.6
316.5
721.6
3,703.2
374.4
142.6
290.7
2,962.5
3,649.3
1,794.7
20,607.2
1,374.1
4,434.0
400.7
975.3
1,001.7
2,058.0
1,389.4
2,075.1
111.8
1,805.3
1,228.1
282.2
13,340.7
867.6
316.8
753.2
3,717.2
365.6
135.2
292.6
3,053.3
Less Developed
More Developed
892,333.9
296,214.3
1,015,318.9
301,804.4
1,131,566.2
309,466.1
1,245,864.6
311,895.6
566,247.2
89,777.1
594,503.9
89,416.6
613,733.9
88,879.5
Sweden
Japan
United States
1,983.9
30,831.2
62,547.6
2,034.2
31,458.0
65,307.8
1,988.5
31,014.1
66,937.1
1,906.9
29,446.4
67,827.5
2.3
2.1
3.5
1.6
1.8
1.9
420.6
7,533.0
19,095.8
417.9
7,913.3
19,317.8
409.8
8,547.2
19,018.9
World Total
1,188,548.2
1,317,123.3
1,441,032.3
1,557,760.2
4.9
3.4
656,024.3
683,920.5
702,613.4
87
Table 7: Immunization and Health
Percent of
pregnant women
fully immunized
against tetanus
1985
Percent of children
fully immunized
by age 1
1985
TB
DPT
Polio
Measles
Africa
37
28
27
38
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Rep.
Chad
Congo
Ethiopia
Gabon
Gambia, The
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania, U. Rep. of
Togo
Uganda
Zaire
Zambia
Zimbabwe
25
60
81
16
37
77
25
6
79
82
2
27
50
14
94
77
2
20
43
14
26
64
75
23
45
39
16
80
11
59
7
14
70
19
9
82
24
11
12
8
16
1
98
31
59
7
77
17
52
8
57
79
1
3
85
7
Population
per
physician
1980
35
23,229
13
19a
52
5
15a
52
71
45
45
10-15
16
15
35
15
76
91
87
13
74
19
74
94
40
58
82
23
20
58
57
80
26
3
56
55
73
99
49
60
21
89
16
21
89
16
59
57
22
30
1
1
1
40
28
23
6
6
19
55
3
11
86
32
45
31
62
54
12
22
56
54
9
22
66
40
21
36
8
45
7
12
89
73
44
18
34
82
87
8
57
52
18
14
16
49
66
8
56
49
9
8
18
47
61
6
47
63
47
22
20
56
53
Near East
62
54
54
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
59
0
79
66
75
68
2
3
33
91
90
52
86
86
54
89
4
96
70
92
47
46
83
50
11
11
32
77
30
91
90
53
86
92
54
90
4
77
48
57
49
25
72
31
62
7
15
48
57
51
25
72
32
62
7
15
52
16,980
48,510
45,020
13,990
26,750
47,640
5,510
69,390
25a
25a
90a
43
88
Percent of
births assisted
by a trained
attendant
around 1980
7,160
17,110
31
7,890
18,640
8,550
10
75
10
52a
40
41,460
14
22,130
10,220
14,500
90
39,140
25
38,790
12,550
20
50
30
2
31,340
13,780
17,520
15,630
5
25
50
50a
8,930
1
1
32
57
20
20-30
38
30
37
17,740
18,100
26,810
13,940
7,670
5,900
44
44
3,211
17
60
70
53
71
83
39
4
10
63
42
62
47
28
62
20
37
8
17
40
100
6
2,630
1
23
59
17
3
12
21
0.1
4
8
6
2
20a
79
100a
65
95a
60
68a
29
74a
970
6,090
1,800
370
900
570
540
730
10,750
1,900
1,670
2,240
50
50
85a
33
3a
3,690
1,630
910
7,120
1,167
Percent of
pregnant women
fully immunized
against tetanus
1985
Percent of children
fully immunized
by age 1
1985
Percent of
births assisted
by a trained
attendant
around 1980
Population
per
physician
1980
29
5,565
5
5a
1“
16,730
7,810
18,160
4,680
TB
DPT
Polio
Measles
Asia (without China)
36
37
31
9
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
18
23
21
25
16
23
11
15
1
11
9
16
12
11
21
60
86
60
91
40
45d
35d
16
14
0.1
16
51
47
4
55
76
65
80
96
43
45
53
67
67
42
76
84
32
34
30
37
100
20
32
30
54
74
65
77
5
74
64
60
4
79
65
61
2
28
4
China
67
74
84
83
Latin America & Caribbean
56
53
68
59
64
1,899
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
89
24
58
90
62
85
98
43
99
50
30
49
57
65
48
16
97
94
99
70
63
33
62
89
61
75
91
20
41
54
21
70
19
59
57
40
35
73
54
48
69
30
86
89
62
75
88“
22
39
54e
2T
67
19
58
56
67
70
71
97
47
67
21
63
91
53
81°
85
19
54
71
23
56
21
53
60
64
49
83
46
53
430
92
92
65
63
66
58°
59
10
59
56
87
47
65a
92
40a
96
96a
49a
36
34a
16
60a
12
34
86
40a
32a
68
65
30
99a
94
96
87
Less Developed
More Developed
45
66
43
44
92
36
87
Sweden
Japan
United States11
31
90
99
81
97
99
95
98
87h
66
98a
World Total
48
50
51
42
Notes appear on page 96
98
96
24
68
49
4
3
3
14
37
25
63
16
18
47
27
23
47
1
19
10a
92a
100
25
27
20
60
60
15
73
1,210
3,690
11,530
430
1,440
10
2
2
90a
4a
24
5
86
450
30,060
13,590
3,480
7,970
37
44
100
85
60
99a
1,150
7,170
7,100
4,190
1,740
6
25
11
1
11
6
4
11
1,930
1,710
1,460
720
2,410
760
3,220
8,610
8,200
3,120
2,830
1,800
980
1,310
1,390
1,360
540
990
5,945
80
100
100
100a
490
780
520
89
Table 8: Nutrition: Breastfeeding, Percent Malnourished,
and Food Production Per Capita
Percent of
infants
of low
birth-weight
1979-83
Percent of children malnourished
Percent of
Index
Daily
Median
Percent of children
children age
of food
per-capita
months
Percent of mothers
production
under age 5
12-23 months
calorie supply
breast
breastfeeding
underweight for age underweight
per capita
as a percent
feeding ________________________
1975-83
1975-83
for height (1969-71 = 100) of requirement
1974-82 3 mos 6 mos 12mos Mild-moderate Severe
1975-83
1982-84 average
1983
Africa
15
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Rep.
Chad
Congo
Ethiopia
Gabon
Gambia, The
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania, U. Rep. of
Togo
Uganda
Zaire
Zambia
Zimbabwe
19
10
12
21
14
13
23
11
15
13
96
95
15
18
13
14
13
8
10
12
13
75
97
95
98
90
97
97
97
85
95
100
70
25
93
89
99
96
95
90
84
98
92
95
50
44
90
64
85
95
97
15
21
90
30
1
40
3
14
19
17
36
2
60
10
41
31
28
23
30
28
2
17
2
21
8
7
7
28
26
30
10
17
24
9
16
21
29
8
23
20
36
62
3
11
16
15
18
20
10
17
12
17
19
16
14
17
10
16
14
15
65
98
30
94
15
90
94
98
100
94
94
100
82
83
91
86
72
85
100
99
70
100
90
20
85
93
88
24
16
3
50
5
43
7
15
4
16
9
11
47
92
92
81
97
61
94
106
83
94
95
96
100
103
77
73
93
92
110
82
78
91
89
100
101
95
88
73
74
113
96
107
112
66
95
69
83
93
114
100
92
98
92
74
69
87
83
93
85
102
88
91
68
109
93
94
Near East
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
90
12
7
14
6
7
7
7
12
9
9
16
79
91
84
70
41
93
93
93
88
95
99
72
92
91
41
71
51
85
80
73
76
58
55
46
1
3
9
3
40
5
9
9
7
8
7
60
4
3
54
4
36
17
66
84
112
83
104
102
112
95
68
97
118
71
97
86
98
102
91
89
118
90
98
94
101
96
84
82
116
79
115
91
99
85
98
136
126
118
118
121
117
145
94
91
155
98
123
84
103
134
127
121
123
83
84
94
92
105
Median
Percent of
infants
months
of low
breastbirth-weight feeding
1979-83 1974-82
Asia (without China)
27
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
20
50
Percent of children malnourished
Percent of
Index
Daily
children age
per-capita
Percent of children
of food
under age 5
12-23 months
production
calorie supply
Percent of mothers
breastfeeding
underweight for age
underweight
per capita
as a percent
1975-83
1975-83_______________________
for height
(1969-71 = 100) of requirement
3 mos 6 mos 12 mos Mild-moderate Severe
1982-84 average
1983
1975-83
110
31
20
98
97
89
63
21
21
90
90
90
50
1
48
9
98
100
9
18
11
17
94
90
97
100
83
93
93
84
90
19
97
3
47
90
34
24
99
99
33
27
5
3
37
17
122
96
110
107
113
127
129
118
90
6
112
111
27
10
3
52
14
16
90
91
95
117
7
1
9
22
18
109
10
25
27
19
20
13
98
68
96
58
90
28
21
19
83
48
74
47
48
20
50
38
62
40
7
27
38
117
110
120
99
18
22
81
119
8
30
14
102
99
104
124
97
34
104
107
68
125
93
79
95
104
115
106
115
123
105
10
China
6
128
111
Latin America & Caribbean
10
104
108
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
6
10
109
84
115
102
104
87
129
119
93
59
91
19
5
7
2
78
38
63
20
44
9
7
66
47
26
9
9
10
9
9
15
10
9
8
9
Less Developed
More Developed
18
7
Sweden
Japan
United States
4
5
7
World Total
16
3
10
13
18
12
12
49
77
4
77
15
93
48
6
7
4
57
62
12
62
80
13
78
6
59
3
51
50
35
56
33
84
60
85
28
40
48
48
77
72
50
21
40
57
55
74
35
72
24
43
46
8
1
6
11
10
4
40
52
70
29
6
1
3
2
18
16
14
27
71
30
49
55
65
48
42
3
3
2
8
1
14
13
30
14
25
8
4
2
99
89
88
101
91
90
99
89
104
78
99
93
82
106
105
110
114
126
105
89
90
95
83
94
111
126
101
98
105
122
84
85
60
105
88
129
99
99
112
106
103
131
112
91
105
116
113
137
110
110
91
Table 9: Education Indicators
Percent of
children enrolled
in primary school3
Males
Females
Percent literate
of population
age 15 and older
Males
Females
Percent of
children enrolled
in secondary' school3
Males
Females
Males Females
1980-84 1980-84
1970
1985
1970
1985
1960 1980-84
1960
1980-84
1980-84
1980-84
Africa
34
57
15
35
El
28
60
19
11
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Rep.
Chad
Congo
Ethiopia
Gabon
Gambia, The
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania, U. Rep. of
Togo
Uganda
Zaire
Zambia
Zimbabwe
16
23
37
13
29
47
26
20
50
8
49
37
73
21
43
68
53
40
71
7
8
44
3
10
19
6
2
19
0
16
69
6
26
45
29
11
55
121
42
102
20
36
98
51
21
19
5
5
27
24
11
23
3
3
16
8
2
34
117
51
70
20
40
64
97
17
28
27
48
21
17
27
23
9
18
12
28
8
4
11
16
57
33
13
54
18
29
112
68
6
10
19
53
8
2
4
6
49
4
43
21
13
26
44
49
27
56
42
11
70
36
64
40
46
53
70
62
47
74
52
23
18
7
6
10
19
74
8
43
18
4
53
15
43
17
17
31
49
84
23
62
31
11
59
14
6
35
89
55
74
19
54
2
14
77
22
71
9
31
43
18
18
5
61
37
38
18
21
5
8
1
33
19
21
6
77
29
28
6
70
38
35
12
27
87
53
29
103
11
52
44
35
68
64
63
45
58
81
14
13
103
60
78
146
90
89
34
55
117
98
55
58
120
85
89
43
88
93
104
95
76
30
45
112
91
15
48
5
9
43
12
4
53
3
25
16
15
24
30
102
18
45
45
6
3
93
36
11
1
5
2
0
2
2
2
0
3
1
2
0
0
1
0
1
0
4
1
68
36
30
13
94
35
64
63
30
17
15
5
85
14
60
42
3
17
1
8
15
19
10
42
109
84
80
49
21
44
4
36
10
15
42
2
12
5
3
1
1
0
89
127
22
46
12
31
3
3
1
2
20
5
13
35
39
12
39
16
8
11
2
7
32
28
19
20
6
4
21
7
9
4
11
4
5
11
28
59
114
91
124
65
18
24
32
32
34
28
45
45
67
67
Near East
49
68
21
44
73
107
43
85
52
35
Algeria
Cyprus
Egypt
Iran Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
39
63
11
37
55
106
37
82
50
35
50
40
50
93
64
65
79
60
34
59
62
90
97
87
76
86
81
45
20
17
18
83
29
42
58
13
10
30
39
87
93
63
63
69
50
22
80
56
94
99
94
131
105
92
67
101
113
113
95
101
96
115
52
27
36
97
59
102
99
24
76
88
99
97
98
94
105
67
47
67
73
79
86
61
45
33
37
83
77
79
63
27
43
41
62
22
89
88
90
25
3
20
14
97
94
81
113
125
116
94
97
107
61
72
56
92
102
107
95
36
21
35
38
42
63
40
47
49
26
16
24
19
28
40
26
28
61
11
2
92
0
19
18
7
30
22
37
47
59
27
2
3
27
66
2
20
17
35
7
9
1
1
1
0
34
53
70
79
84
81
76
68
86
3
2
1
7
46
48
27
52
61
66
63
15
60
44
69
24
31
9
Percent of
20-24-year-olds
enrolled in postsecondary school
33
63
65
88
51
100
136
2
39
43
58
5
Percent of
children enrolled
in primary school3
Percent literate
of population
age 15 and older
Males
Males
Females
Females
Percent of
children enrolled
in secondary school3
Percent of
20-24-year-olds
enrolled in post
secondary school
Males
Females
Males
1980-84 1980-84
1970
1985
1970
1985
1960
1980-84
1960
1980-84
1980-84
1980-84
Asia (without China)
53
61
29
38
77
97
45
74
43
28
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
13
36
39
43
2
12
8
22
15
66
5
61
19
67
32
2
26
9
55
17
11
26
6
5
11
1
109
105
68
112
72
64
44
42
75
70
24
31
102
98
92
21
50
86
12
49
85
90
47
66
71
57
90
95
57
83
81
81
29
65
93
80
86
52
111
107
100
118
79
40
58
4
15
2
8
5.8
2.7
37
2
16
1
7.1
3
2.0
1
94
37
71
81
28
48
76
66
99
34
108
104
92
81
100
89
16
83
87
23
39
30
83
39
55
40
86
74
3
24
11
80
12
35
19
85
79
19
59
46
98
105
100
68
56
115
78
1
7
13
93
107
43
55
30
113
82
34
15
20
61
90
10
8
8
66
82
85
86
93
91
94
55
69
72
79
83
88
121
100
88
115
104
101
90
79
111
99
68
52
69
56
13
4
10
4
120
105
53
43
4
1
116
93
41
27
2
1
China
82
Latin America & Caribbean
75
84
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
94
68
69
90
79
88
86
69
75
61
51
94
26
55
96
78
58
81
84
81
96
84
79
95
93
79
97
Less Developed
More Developed
Sweden
Japan
United States5
64
20
42
23
Females
89
94
78
85
75
63
97
40
61
92
89
91
91
55
92
46
63
88
76
87
87
65
68
53
37
89
17
50
97
69
57
81
75
60
95
65
76
87
93
77
80
69
47
95
35
58
88
88
85
78
91
109
87
105
51
51
98
78
97
111
77
97
109
99
87
82
50
107
50
68
92
82
65
98
105
95
107
94
106
112
119
103
111
104
117
69
78
99
74
101
106
120
97
106
107
120
99
50
93
107
77
95
109
98
79
77
39
106
42
67
93
77
66
94
90
71
107
81
99
110
122
100
105
115
114
69
67
99
64
1001
107
117
103
101
99
112
57
38
62
32
23
27
62
48
41
71
68
49
46
77
13
9
53
23
16
58
13
31
56
56
36
55
37
64
54
25
15
62
12
34
60
53
42
62
35
57
14
10
3
3
11
8
19
13
19
0
27
11
11
26
0
16
107
110
106
87
111
100
108
107
104
69
72
6
18
4
24
37
46
38
40
54
36
21
60
95
88
89
93
71
85
89
111
100
53
70
32
48
75
104
48
83
42
29
99
99
99
99
99
99
99
99
95
103
100
97
100
99
96
102
100
98
100
98
80
93
99
90
95
98
World Total
Notes appear on page 96
93
Table 10: Economic and Water and Sanitation Indicators
Gross National Product
per capita in 1983 US $
1960
1983
53
21
90
26
98
27
90
12
15
72
31
22
29
15
50
52
42
7
72
69
21
30
85
37
71
73
66
37
80
95
50
33
2
37
10
15
11
20
9
49
0
6
18
24
3
75
20
4
0
35
41
60
33
30
36
3
30
90
65
70
60
27
6
21
60
87
46
48
60
40
55
63
61
65
85
100
31
73
60
85
68
45
41
26
12
34
8
10
65
33
100
48
31
84
I
91
31
100
88
100
64
100
100
25
40
97
22
17
100
65
95
100
85
90
100
98
100
63
95
85
100
68
54
100
33
75
21
40
65
55
55
15
85
40
30
56
60
65
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon, U. Rep. of
Central African Rep.
Chad
Congo
Ethiopia
Gabon
Gambia, The
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Senegal
Siena Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania, U. Rep. of
Togo
Uganda
Zaire
Zambia
Zimbabwe
1,609
299
334
189
207
531
345
220
705
117
358
1,829
465
422
226
243
303
225
769
717
1,670
240
770
3,920
270
440
330
250
2,240
400
870
240
280
220
170
580
740
Near East
877
2,385
22
Algeria
Cyprus
Egypt
Iran, Islamic Rep. of
Iraq
Israel
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Saudi Arabia
Syrian Arab Rep.
Tunisia
Turkey
United Arab Emirates
Yemen, Democratic
Yemen
1,831
1,267
336
2,320
3,670
690
20
3,295
5,270
1,720
16,200
94
682
279
166
533
448
152
162
348
849
539
1,415
390
658
233
515
3,071
626
1,715
794
815
815
1,220
120
3,430
290
320
300
190
710
340
560
480
310
210
150
480
1,160
8,460
760
6,230
12,220
1,790
1,290
1,250
22,770
520
550
Percent of
population
with access to
sanitation facility
1983
Urban
Rural
26
64
549
290
880
180
240
820
280
Percent of
population
with access to
safe water
1975-1983
Urban
Rural
65
33
Africa
234
567
255
585
Percent of
population
below absolute
poverty level
1977-83
Urban
Rural
30
10
50
23
50
25
27
26
55
55
12
12
10
42
50
85
48
95
7
10
5
80
25
21
14
28
20
45
15
20
63
81
25
75
Gross National Product
per capita in 1983 US $
1960
1983
Asia (without China)
Afghanistan
Bangladesh
Bhutan
Burma
East Timor
Fiji
Hong Kong
India
Indonesia
Kampuchea
Korea, Dem. Rep. of
Korea, Rep. of
Laos People’s Dem. Rep.
Malaysia
Melanesia
Micronesia
Mongolia
Nepal
Papua New' Guinea
Pakistan
Philippines
Polynesia
Singapore
Sri Lanka
Thailand
Viet Nam
China
Percent of
population
below absolute
poverty level
1977-83
Urban
Rural
Percent of
population
with access to
safe water
1975-1983
Urban
Rural
255
443
39
48
67
18
36
129
130
86
86
28
29
141
180
40
40
36
1,302
213
297
1,780
6,070
260
560
40
26
51
44
621
2,010
18
11
30
28
97
60
20
71
100
11
10
24
55
91
53
75
16
3
6
47
100
0
50
44
70
191
160
760
390
750
55
10
61
75
32
32
29
71
55
78
41
53
34
100
76
50
6,660
330
820
15
21
48
93
47
29
38
203
351
2
8
100
80
40
100
13
1,537
31
15
1,870
517
16
43
14
21
809
222
42
Percent of
population
with access to
sanitation facility
1983
Urban
Rural
26
70
31
1
13
1
30
31
4
59
121
300
Latin America & Caribbean
1,459
1,423
35
46
87
44
60
16
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Trinidad and Tobago
Uruguay
Venezuela
3,508
1,084
1,096
2,510
30
65
35
17
12
94
40
32
1,890
1,410
1,070
35
34
53
18
33
2,280
923
1,032
72
78
86
100
851
45
40
20
21
3,039
2,914
1,160
1,420
680
1,110
560
290
670
1,270
2,180
880
2,110
1,320
1,040
3,800
6,830
2,470
3,830
Less Developed
More Developed
408
599
Sweden
Japan
United States
7,925
2,825
9,636
12,440
801
853
666
326
650
1,408
1,221
961
1,066
836
1,102
480
1,870
85
85
45
100
99
55
43
65
32
25
14
78
55
80
21
21
19
19
30
50
49
39
25
85
98
0
79
99
91
32
21
42
26
60
25
55
91
90
100
58
100
96
49
4
13
100
41
64
9
26
34
48
41
50
28
80
12
40
40
78
12
73
26
10
18
61
92
57
84
0
100
96
100
96
95
3
91
97
46
100
65
36
9
75
42
2
37
27
10,100
14,080
World Total
95
Notes to Appendix Tables
Tables 1-6
Tables 1 through 4 exclude countries with populations below 500.000 in 1980 in regional and
world totals; Less Developed and World totals in Tables 5 and 6 include all countries.
Table 2
a Values of 0.0 represent fewer than 50 deaths.
Table 4
a Values of 0.0 represent fewer than 50 deaths.
Table 5
a This statistic is negative because the population is declining.
Table 7
a Delivered in an institution.
b Measles immunization given at, or later than, 12 months and up to 60 months of age.
c Figures for the United States represent the percent of children aged 5-6 entering first grade who
have been fully immunized for the specified diseases. The United States does not require
immunization for tuberculosis with BCG.
d Less than 24 months of age.
e Two doses only.
Table 9
a Percent of children enrolled is a gross enrollment ratio and may exceed 100 if persons older or
younger than the conventional age group are attending.
b 1980-84 percent of children enrolled combines primary and secondary enrollments.
96
APPENDIX 2.
METHODOLOGY OF PROJECTIONS
The projections presented in Appendix 1 are based on two
scenarios of infant and child mortality: the first assumes
there will be no changes in mortality; the second assumes
reductions in mortality adequate to achieve internationally
stated goals by the year 2000. These projections have been
prepared to illustrate the differences in numbers of children
who will live and die if the impediments to child survival
discussed in this report either continue or are removed.
The data show both the numbers of children who will sur
vive as a result of changes in mortality, and the reductions
in the percent dying that must be achieved for global goals
to be reached.
Mortality goals for the year 2000 are based on infant mor
tality goals suggested by the United Nations and AID: levels
of infant mortality below 10.0 (percent dying before age 1)
would be reduced by half; levels of infant mortality from
10.0 percent to 12.5 percent would be reduced to 5.0 per
cent; in accordance with AID, levels of infant mortality
above 12.5 percent would be reduced to 7.5 percent.
Because reductions in infant mortality are generally slower
below 1.0 percent and uncommon below .5 percent, infant
mortality rates below 1.0 percent would be reduced to .5
percent. Reductions in mortality are not the same for all
countries. Countries with high proportions of infants dying
(e.g., Afghanistan and Sierra Leone) would drop to 40 per
cent of their current level; countries with low proportions
of infants dying (e.g., Japan and Sweden) would drop to 70
percent of their current level.
The data used in the projections are primarily from the
United Nations. Numbers of births are the medium variant
of the Population Division’s World Population Pros
pects: Estimates and Projections as Assessed in 1984. The
same numbers of births are used for both scenarios. The 5
years of births are divided into 4 and 1 years of births (to
estimate numbers of infants and 1-4 year olds) with an ad
justment for growth in the number of births from 1980 to
2000. Estimates of mortality levels are based on the percent
of children dying before age 1 during the period 1980-85
and before age 5 as of 1983, and are derived from the
United Nation’s Population Division and from UNICEF, The
State ofthe World’s Children 1986. For 12 countries (Gabon,
Gambia, Namibia, Reunion, Swaziland, Cyprus, East Timor,
Fiji, Melanesia, Micronesia, Polynesia, Puerto Rico) percent
dying before age 5 is estimated from the level of infant mor
tality and the Coale-Demeny model life tables. Estimates
of the numbers of children alive at each quinquennial are
based on either a continuation of the “current”
1980-85/1983 percents dying, or the “reduced” percents
dying, which are a linear decrease from the 1980-85/1983
level to the 2000 goal. Separation factors are from the
Coale-Demeny model life tables. Male and female separa
tion factors are adjusted to a one-sex population, assuming
a sex ratio at birth of 105 males to 100 females. The region
“west” is used for all areas except SubSaharan Africa, where
“north” is used. All countries converge to a “west” pattern
of child mortality, with the level of 1 through 4 mortality
based on the stated goal for infant mortality.
Child mortality rates are presented as 5q0; the percent of
children who will die before the age of 5. Though less com
mon, this statistic is easy to understand and compare with
infant mortality. As used in this report, 5q0 minus the in
fant mortality is the number of children, from 100 births,
who will die between their first and fifth birthday. 5q0 was
also chosen because it is used in the U.N. Population Divi
sion and UNICEFs first internationally standardized set of
infant mortality estimates and projections. Comparisons
of stated goals and expected levels is simplified by the
presentation of statistics in the same format.
97
APPENDIX 3.
DEFINITIONS AND SOURCES OF DATA
BIRTHS: Number of births that will occur in a country
according to U.N. medium level growth projections.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
CRUDE DEATH RATE: Annual number of deaths per
1,000 persons.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
BREASTFEEDING, MEDIAN DURATION, IN MONTHS:
Number of months after a birth after which half of mothers
no longer breastfeed their children.
Source: World Fertility Survey Data. Ferry, Benoit, and D.P
Smith. 1983. Breastfeeding Differentials. WES Comparative
Studies number 23. Voorburg, Netherlands. International
Statistical Institute. Table 3, page 15.
DOUBLING TIME: Number of years until 1985 popula
tion would double at the 1985 rate of growth.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
BREASTFEEDING 3, 6, 12 MONTHS, PERCENT OF
MOTHERS: Percent of mothers who are still breastfeeding
their child 3,6, or 12 months after birth, exclusively or in
addition to other foods.
Source: UNICEF. The State of the World’s Children 1986. New
York: Oxford University Press. Table 2, pp. 134-35.
CALORIES, DAILY PER CAPITA SUPPLY AS A
PERCENT OF REQUIREMENTS: Daily per capita calorie
supply was calculated by dividing the calorie equivalent of
the food supplies in a country by the population (supplies
include domestic production, imports less exports and
changes in stocks). Requirements are the number of calo
ries needed to sustain a person at normal levels of activity
and health, taking into account age and sex distributions,
average body weights, and environmental temperatures.
Source: World Bank, 1986 World Development Report,
Washington, D C., Table 28, pp. 234-35.
CHILDREN AGE 1-4, NUMBER OF: Numbers of children
age 1 through 4, on July 1 of a given year, based on births
1 to 5 years ago, and each of 2 mortality scenarios. For a
discussion of the methodology see the Methodology of Pro
jections section.
Source: Births and prevailing mortality rates arefrom United
Nations, 1986. World Population Prospects: Estimatesand Pro
jections as Assessed in 1984. New York: United Nations; and
UNICEF. The State of the World’s Children 1986. New York:
Oxford University Press. Table 5, pp. 140-141.
CRUDE BIRTH RATE: Annual number of births per 1,000
persons.
Source: United Nations. 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
98
DYING BEFORE AGE 1 AND 5, NUMBERS: Number of
infants, and children age 1 through 4, who die during a
given year.
Source: see Methodology of Projections section.
DYING BEFORE AGE 1 AND 5, PERCENT: Percent of
children who do not survive from birth to exact age 1, and
from birth to exact age 5. Percent dying before age 1 are part
of the percent who die before age 5, similar to a IqO and
5q0.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations, and UNICEF. The State of the World’s
Children 1986. New York: Oxford University Press. Table 5, pp.
140-141; for projections ofpercents dying see the Methodology
of Projections section.
FOOD PRODUCTION PER CAPITA, INDEX OF: This
index shows the average annual quantity of food produced
per capita over a three year period from 1982 to 1984, ex
pressed as a percent of average food production from the
base period 1969-71.
Source: Food and Agriculture Organization of the United
Nations, maintained on the economic and social data base
of AID.
GROSS NATIONAL PRODUCT, PER CAPITA: Gross
national product at current market prices in U.S. dollars
divided by the population. Dollars for 1960 have been con
verted to their value in 1983 dollars. One 1960 dollar is
equal to 3.367 1983 dollars.
Source: World Bank. 1986. World Bank Atlas. Washington,
DC.: World Bank, page 6; data for 1960 are from a previous
World Bank Atlas, maintained in a computer data bank, the
Economic and Social Data Base of AID.
IMMUNIZED, PERCENT OF 1-YEAR-OLDS FULLY: The
estimated percent of children in 1984 who were fully im
munized against each disease or group of diseases by ex
act age 1. The requirements for full immunity depend on
the type of vaccine. The vaccination schedule recom
mended by the World Health Organization is as follows:
Tuberculosis: 1 injection of BCG (Bacterium CalmetteGuerin), which can be given at the time of birth.
Diphtheria, Pertussis, Tetanus: 3 injections with DPT vac
cine before age 1; the first is recommended 6 weeks after
birth followed by 2 more at 1-month intervals (i.e.,10 weeks
and 14 weeks).
Polio: At least 3 doses of oral polio vaccine before age 1,
given 1 month apart. In areas where polio is endemic, the
first dose is recommended at the time of birth, followed by
3 more doses at the same time as the DPT injections.
Measles: 1 injection of measles vaccine, given after 9
months in developing countries. Because measles vaccine
is usually given later in developed countries, estimates of
immunization coverage in these countries are based on the
number of children under 5 who have been vaccinated
against measles.
Source: World Health Organization/Expanded Program on
Immunization (EPI). Official immunization coverage estimates
available as ofJanuary 20,1986.
IMMUNIZED, PERCENT OF PREGNANT WOMEN
FULLY IMMUNIZED FOR NEONATAL TETANUS: The
estimated percent of women giving birth in 1984 who
received 2 tetanus toxoid injections or 1 booster dose
during pregnancy.
Source: World Health Organization/Expanded Program on
Immunization (EPI). Official immunization coverage estimates
available as ofJanuary 20, 1986.
INFANTS, NUMBER OF: Numbers of children younger
than age 1, on July 1 of a given year, based on births during
the last yearand each of 2 mortality scenarios. For a discus
sion of the methodology see the Methodology of Projec
tions section.
Source: Births and “current” 1980-85 mortality rates are from
United Nations. 1986. World Population Prospects: Estimates
and Projections as Assessed in 1984. New York: United
Nations.
INFANT MORTALITY GOALS: Goals for the year 2000
are: reduce rates from 12.5 percent or higher to 7.5 percent;
reduce rates from 10.0 to 12.4 percent to 5.0 percent; reduce
rates from 1.1 to 9.9 percent to half their current level;
reduce rates of 1.0 percent and less to .5 percent.
Source: statements by United Nations and AID; see the
Methodology ofProjections section.
LESS DEVELOPED: For statistical purposes, the less
developed areas are defined as Africa, the Near East, Asia,
Latin America, and the Caribbean.
LIFE EXPECTANCY: The number of years a person would
live if exposed to the mortality rates that each age group ex
periences in a given year.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
LITERACY: Percent of persons aged 15 and older who can
read and write. Definitions of ability can differ greatly from
country to country.
Source: UNESCO. Statistical Yearbook 1985.
LOW BIRTH WEIGHT: 2,500 grams (5.5 pounds) or less.
Source: UNICEF. The State ofthe World’s Children 1986. New
York: Oxford University Press. Table 2, pp. 134-35.
MALNOURISHED, MILD/MODERATE AND SEVERE,
PERCENT OF CHILDREN UNDER 5: Mild/moderate is
between 60 percent and 80 percent of desirable weight for
age; severe is less than 60 percent of desirable weight for
age.
Source: UNICEE The State ofthe World’s Children 1986. New
York: Oxford University Press. Table 2, pp. 134-35.
MALNOURISHED, UNDERWEIGHT FOR HEIGHT:
The percent of children with less than 77 percent of the
median weight-for-height of the U.S. National Center for
Health Statistics reference population.
Source: UNICEF. The State of the World’s Children 1986. New
York: Oxford University Press. Table 2, pp. 134-35.
MORE DEVELOPED: For statistical purposes, the more
developed areas are defined as Europe, the USSR, North
America, Japan, Australia, and New Zealand.
MORTALITY, 1980-85 LEVEL AND REDUCED LEVEL:
Percent of children who would die before their first, or fifth,
birthday if mortality rates prevailing in 1980-85 continue,
or if there is a linear decline to mortality goals for 2000.
Source: “Current” 1980-85 mortality rates are from United
Nations, 1986. World Population Prospects: Estimates and Pro
jections as Assessed in 1984. New York: United Nations; and
UNICEE The State ofthe World’s Children 1986. New York:
Oxford University Press. Table 5, pp. 140-141; for projected
mortality rates, see the Methodology of Projections section.
MORTALITY RATE, INFANT: The number of deaths to
infants under 1 year of age in any calendar year per 1,000
live births. This report uses the more common percent rate
and expresses rates per 100, rather than per 1,000.
99
PHYSICIAN, POPULATION PER: A country’s total
population in 1980 divided by the number of physicians
in that country.
Source: World Bank. 1985. World Development Report.
Washington, D C., table 24, pp. 220-21.
POVERTY, ABSOLUTE LEVEL: That income level below
which a minimum nutritionally adequate diet plus essen
tial non-food requirements is not affordable.
Source: UNICEF. The State ofthe World’s Children 1986. New
York: Oxford University Press. Table 6, page 142-43.
SANITATION FACILITIES: Sanitation facilities may in
clude the collection and disposal, with or without treat
ment, of human excreta and wastewater by water-borne
systems or the use of pit latrines and similar installations
(no definition provided in the source document; this
definition is from WHO. 1976. World Health Statistics
Report, vol. 29, no. 10. Geneva).
Source: United Nations General Assembly, Economic and
Social Council. 1985. Report of the Secretary-General. Progress
in the Attainment of the Goals of the International Drinking
Water Supply and Sanitation Decade.
SCHOOL ENROLLMENT, PRIMARY, SECONDARY
AND POST-SECONDARY: The enrollment ratio is the
total number of children enrolled in school, whether or not
they belong in the relevant age group for that level, express
ed as a percent of the total number of children in the rele
vant age group for the level. Percents may exceed 100 if per
sons who are older than the conventional age are attending.
The relevant age group is defined by individual country
educational systems, except for post-secondary school,
when 20-24 is always the age group used.
Source: UNESCO. Statistical Yearbook 1985.
TOTAL FERTILITY RATE: The average number of
children that will be bom to a woman if she lives through
her reproductive years and bears the same number of
children as women at each age group bear in a given year.
Source: United Nations, 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United NationsZ.T>lrf
TOTAL roPtll^TlOl^ TJiAp
of persons resi
dent ii\-a'g^erccou^t^^p J J^ily.of d-given year, irrespec
tive of ri&tfonality.--Source: Unhed:Natio^rf98^Wbrld Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
100
TRAINED ATTENDANT, PERCENT OF BIRTHS
ASSISTED BY: Trained attendants include physicians,
nurses, midwives, trained primary health care and other
health workers, and trained traditional birth attendants.
National coverage levels are drawn from official estimates
and sample surveys over a broad 10-year period. If no direct
figures were available,the percent of births in institutions
has been substituted as a conservative estimate for trained
attendant coverage.
Source: World Health Organization/Division ofFamily Health.
URBAN: Varies according to national definitions; caution
is advised in country-to-country comparisons (e.g., Nigeria
uses a size cutoff of 20,000 persons, Peru uses a size cutoff
of 100 occupied dwellings, Chile looks for the presence of
certain public and administrative services, and many coun
tries merely name a few cities). Rural is defined as the rest
of the country.
Source: Individual countries, United Nations, 1986. World
Population Prospects: Estimates and Projections as Assessed in
1984. New York: United Nations.
WATER, ACCESS TO SAFE/ADEQUATE DRINKING:
“Safe” commonly includes treated surface waters or un
treated but uncontaminated water such as that from pro
tected boreholes, springs, and sanitary wells. “Reasonable
access” in urban areas is defined as a public fountain or
stand post located not more than 200 meters from a house.
In rural areas reasonable access is when members of the
household do not have to spend a disproportionate part of
the day in fetching the family’s water needs (no definition
provided in the source documents; this definition is from
WHO. 1976. World Health Statistics Report, vol. 29, no. 10.
Geneva).
Source: United Nations General Assembly, Economic and
Social Council, 1985. Report of the Secretary-General. Progress
in the Attainment of the Goals of the International Drinking
Water Supply and Sanitation Decade. Where data were not
available for 1983, the source is UNICEF. The State of the
World’s Children 1986. New York: Orford University Press.
Table 3, pp. 136-37.
WOMEN OF REPRODUCTIVE AGE, NUMBERS OF:
The total number of women age 15 through 49 resident in
a given country on 1 July of a given year, irrespective of
marital status and fertility.
Source: United Nations. 1986. World Population Prospects:
Estimates and Projections as Assessed in 1984. New York:
United Nations.
APPENDIX 4.
COUNTRIES AND REGIONS
Data are presented for all developing countries with a 1980
population of at least 500,000. Several small south Pacific
nations have been grouped together. These groups are:
Melanesia, which includes New Caledonia, Solomon
Islands, and Vanuatu; Micronesia, which includes Guam,
Kiribati, Nauru, Pacific Islands, Tuvalu, Johnston Island,
Midway Islands, Pitcairn, Tokelau, and Wake Islands;
Polynesia, which includes American Samoa, Cook Islands,
French Polynesia, Niue, Samoa, Tonga, Wallis, and Futuna
Islands. Data for three developed nations, the United States,
Sweden, and Japan, are presented for comparative
purposes.
Regions are based on AID country groupings. It should
be noted that AID, the United Nations and the World
Health Organization group countries into slightly different
regions.
Except as otherwise noted, regional statistics are weighted
averages of statistics of countries for which data are
available. Total population statistics (e.g., Gross National
Product) are weighted by the 1985 total population of
countries; infant statistics (e.g., mortality and immuniza
tion) are weighted by the number of births or 1-year olds.
Because dates of information vary, regional estimates may
be composed of statistics and weights of different dates.
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Slides, Diskettes, and Multiple Copies
for Lecturing, Teaching, and Further Analysis
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Child Survival:
A Policy and Program Choice
" %
Every year, at current mortality rates, another 15
million children under age 5 die in the developing
world—more than 1,700 each hour. One child in
seven fails to reach his or her 5th birthday. In
developed countries, by contrast, 98 percent of
children survive to age 5.
The enormous differences in risk that children face
around the world are at once unjust and unnecessary.
Most childhood deaths result from preventable or
treatable causes.
Remarkable advances in methods of improving
child survival have been made in recent decades.
Among the most important are new or improved vac
cines against infections, oral rehydration therapy
(ORT) for acute diarrheal disease, and modem family
planning methods that enable couples to plan the
number and spacing of births.
These safe, effective keys to child health can save
millions of lives annually. We have in our hands the
knowledge and resources to revolutionize child sur
vival.
What is needed now is the political and social will
to institute appropriate policies, and to initiate and
sustain the health and development programs that
spell survival for the most vulnerable of the world’s
children.
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