Global Burden of Child Deaths

from All Africa

The East African (Nairobi)

By Zachary Ochieng

MORE THAN A THIRD OF child deaths and 11 per cent of the total disease burden worldwide are due to maternal and child undernutrition.

These and other stark findings are the conclusions of an international group of investigators publishing their findings in The Lancet, a medical journal published in London.

In a series of maternal and child undernutrition articles under the title, Maternal and Child Undernutrition: An Urgent Opportunity, Dr Richard Horton, editor of The Lancet, public health scientists Robert Black, Zulfigar Bhutta, Jennifer Bryce, Saul Morris and Cesar Victora argue that nutrition is a desperately neglected aspect of maternal, newborn, and child health.

"The reasons for this neglect are understandable but not justifiable. When one considers specific actions to improve maternal and child survival, one is drawn to particular interventions - vaccination, oral rehydration therapy, and the treatment of infection and haemorrhage. In recent years, this portfolio of responses has broadened to embrace the health system - human resources, financing, and stewardship.

Somehow, nutrition has slipped through the gap," the authors say.

"And yet we know that nutrition is a major risk factor for disease. What public health experts and policymakers have not done is to gather the evidence about the importance of maternal and child nutrition, catalogue the long-term effects of undernutrition on development and health, identify proven interventions to reduce undernutrition, and call for national and international action to improve nutrition for mothers and children," the authors contend.

According to the authors, undernutrition is the largely preventable cause of over a third - 3.5 million - of all child deaths. Stunting, severe wasting, and intrauterine growth restriction are among the most important problems. There is a golden interval for intervention - from pregnancy to 2 years of age. After 2 years, undernutrition will have caused irreversible damage to future development towards adulthood.

INCREDIBLY, FOUR-FIFTHS OF UNdernourished children live in just 20 countries across four regions - Africa, Asia, western Pacific, and the Middle East. These are the priority nations for action.

In terms of under-5 mortality rates, the most immediate needs are for Afghanistan, Democratic Republic of Congo, Nigeria, Ethiopia, Uganda, Tanzania, Madagascar, Kenya, Yemen, and Burma. In order of population size, and excluding the countries with highest mortality rates, the ranking is different: India, Indonesia, Pakistan, Bangladesh, Vietnam, Philippines, Egypt, South Africa, Sudan, and Nepal.

Yet there are proven effective interventions to reduce stunting and micro-nutrient deficiencies. According to strict criteria around admissible evidence, breastfeeding counselling, vitamin A supplementation and zinc fortification have the greatest benefits. Attention to maternal nutrition through adequate dietary intake in pregnancy and supplementation with iron, folic acid, and possibly other micronutrients and calcium are likely to provide value. But these interventions need additional programmatic experience about how to achieve full coverage.

The authors say there is no magic technological bullet to solve the problem of undernutrition.

Long-term investments in the role of women as full and equal citizens - through education, economic, social, and political empowerment - will be the only way to deliver sustainable improvements in maternal and child nutrition, and in the health of women and children more generally.

The compelling logic of this scientific evidence is that governments need national plans to scale-up nutrition interventions, systems to monitor and evaluate those plans and laws and policies to enhance the rights and status of women and children. Although complex and fraught with political disagreement, none of these solutions are separable from global treaties and negotiations over trade, agriculture and poverty reduction.

"The international nutrition system is broken. Leadership is absent, resources are too few, capacity is fragile and emergency response systems are fragmentary. New governance arrangements are urgently needed. An agency, donor, or political leader needs to step up to this challenge. There is a fabulous opportunity right now for someone to do so. But who?," ask the authors.

"Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden," the authors say.

BY DOING AN ANALYSIS THAT accounted for co-exposure of nutrition-related factors, the authors found that these factors were together responsible for 35 per cent of child deaths globally and 11 per cent of the total disease burden.

The paper concludes by making a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences.

The authors also state that poor foetal growth or stunting in the first two years of life can lead to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income and decreased offspring birthweight for women. The researchers analysed the association between child and maternal undernutrition with human capital and risk of adult disease in low and middle income countries, focusing on five longstanding studies in Brazil, Guatemala, India, the Philippines and South Africa.

They showed that indicators of undernutrition at the age of two were related to adult outcomes. Further, they found that children who are undernourished in the first two years of life, and who put on weight rapidly later in childhood and in adolescence are at a high risk of chronic diseases related to nutrition. But they found no evidence that rapid weight gain or height gain in the first two years of life increases the risk of chronic disease, even in children with poor foetal growth.

The authors conclude by saying "...damage suffered in early life leads to permanent impairment and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits."

Yet implementation of existing maternal and child nutrition-related interventions could prevent a quarter of all child deaths in the 36 countries with the highest burden of undernutrition.

Breastfeeding counselling and vitamin A supplementation are currently the nutrition strategies with the greatest potential to cut child deaths, comment the authors.

They studied how a variety of nutritional factors affected children's growth patterns and risk of death.

In populations with enough food, education about complimentary feeding increased the height-for-age score, while provision of food supplements increased the score further in food-insecure populations.

Further, the authors also found that management of severe acute malnutrition using World Health Organisation guidelines can reduce case-fatalities related to this condition by 55 per cent, but this requires admission to a health facility. The authors add that nutrition strategies on their own are not enough, concluding by saying, "Attention to the continuum of maternal and child undernutrition is essential to attainment of several of the Millennium Development Goals and must be prioritised globally and within countries... What is needed is the technical expertise and the political will to combat undernutrition in the very countries that need it most."

The authors also contend that 80 per cent of the world's undernourished children live in just 20 countries, and intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal and greatly increase the chances of achieving goals for child and maternal mortality. They address seven key challenges for addressing undernutrition at national level, including getting nutrition on the list of priorities, and keeping it there.

The paper looks at the varied situation within and across Latin American countries, which as a whole have experienced a large drop in stunting, being underweight and wasting; and China, where a multi-sectoral approach has seen rapid nutritional improvement.

The authors caution that nutrition resources should not be used to support actions unlikely to be effective in the real life setting of a particular country, nor to support actions that have not been proven to have a direct effect on undernutrition.

They ask, "What can be done?...There are no simple prescriptions to reduce undernutrition, although high coverage with four or five of the proven interventions would certainly have a sizeable effect," charging leaders at country level to review their existing strategies and programmes.

According to the authors, the international nutrition system - made up of international and donor organisations, academia, civil society and the private sector - is fragmented and dysfunctional, and needs reform.

They say: "Financial, intellectual, and personal linkages bind these organisations loosely together as components of an international nutrition system... We argue that such a system should deliver in four functional areas: stewardship, mobilisation of financial resources, direct provision of nutrition services at times of natural disaster or conflict, and human and institutional resource strengthening."

Their analysis of evidence to date finds that currently, there are substantial shortcomings in each of the areas above.

FRAGMENTATION, LACK OF evidence for prioritised action, institutional inertia, and failure to join up with promising developments in parallel sectors are recurrent themes. Many problems are systemic within organisations in the field. They suggest five priority areas for action to create a much stronger international nutrition system, and call for research leadership in areas that matter.

The authors conclude by saying: "The moment is ripe for these reforms. Their implementation would transform the political salience of undernutrition, and offer the chance of a better, more productive life to the 67 million children born each year in the countries most severely afflicted by undernutrition."