COLUMN ONE : ‘Theirs Are the Silent Deaths’ : Why is the Third World still losing so many children to diseases a few cents of medicine could cure? Aid cuts, fatigue and other woes are slowing the battle to save the young.

In this village so wretchedly and desperately poor that residents sometimes must catch and eat rats, death came for Sonia this August. The skinny 3-year-old broke out in fever and began to gasp one rainy, cool evening. After consulting a quack, her parents confined Sonia to their dark shack for five days and nights without medical care.

But her fever and breathlessness continued and her mother and father grew worried. Spotted with rashes, Sonia was finally carried from her community of thatched mud huts, in a lurching bullock cart, down a slimy, monsoon-flooded track to a hospital 10 miles away.

It was too late. Two weeks after falling ill, Sonia died. Her mother, Phoolwa Devi, blames the Hindu mother goddess. “It was not in our hands,” the gaunt, illiterate woman said stoically as she breast-fed Sonia’s 1-year-old sister. “It was the wrath of Mata, and we just have to bear it.”

The young child in the state of Bihar, the dirt-poor land south of the Himalayas where the Buddha once preached, died of complications from common measles. Rubeola--which for American children has come to mean little more than a day or two home from school and a dose of antibiotics--remains a dreaded mass killer in India and other poor nations of Asia, Africa and Latin America. In 1993, the World Health Organization calculates, 1.16 million children younger than 5 contracted the disease and died.

With only a few years left before the 21st Century begins, this great loss of life goes on, with much of the world taking little notice. In the planet’s most impoverished backwaters, from Afghanistan to Zaire, other pathogens--cholera, shigella and about 30 diarrhea-causing microbes--kill more than 3 million children annually, WHO reported. Pneumonia and other acute lung infections, now childhood’s deadliest enemies, claim 4.1 million more.

Such deaths happen with little publicity and kindle only a modicum of outrage, even in countries that are among the worst afflicted. Open a newspaper or listen to a news broadcast in many regions of the globe and you might conclude that the medical emergencies facing humanity are the AIDS pandemic, this year’s alarming outbreak of the fatal, incurable Ebola virus in Equatorial Africa, and the mysterious mutations detected in increasingly drug-resistant microbes.

Yet each year, WHO reports, 12.2 million children younger than 5 die, most from preventable causes. That’s one death every 2.5 seconds.

How could such an enormous, routine waste of young lives be halted? “In many cases, for a few U.S. cents,” WHO says.

“Theirs are the silent deaths,” is the sad verdict of A. Mushtaque R. Chowdhury, who holds a doctorate from the London School of Hygiene and Tropical Medicine and is a social activist in Bangladesh, one of the poorest, most densely populated countries.

Common Scourge

To be sure, the lethal significance of acquired immune deficiency syndrome is great in a Third World country such as India, where confirmed carriers of the human immunodeficiency virus number 21,131, a figure that is fast increasing. But the poor, and especially the children of the Earth, face simultaneous and more common medical emergencies--ones no less dire.

In India alone, more children in a single day die from diarrhea and its energy-sapping complications such as malnutrition than the nationwide toll from AIDS since it was first detected nine years ago in Bombay. That is at least 1,900 child deaths a day, almost the equivalent of five Boeing 747s loaded with infants and preschoolers crashing with the loss of all on board.

And each day, the disaster recurs.

Half a world away, in Mexico, the toll of the young remains so great that when Indians in the impoverished state of Chiapas took up arms on Jan. 1, 1994, one reason they gave was that their children were dying of curable afflictions, including diarrhea.

In fact, deaths from diarrhea could be slashed by at least two-thirds with packets of soluble electrolytic salts priced at a few cents each or home remedies that cost next to nothing if parents know how to concoct them, says Dr. Udai Bodhankar, president of the Indian Academy of Pediatrics.

But not enough is being done--by doctors and health institutions, pharmaceutical companies, governments and schools, international agencies and charities, and the richer countries where boys and girls are infinitely safer.

“There should be a moral minimum guaranteed for all children,” said Dr. Monica Sharma, a senior health adviser at the New York headquarters of the United Nations Children’s Fund (UNICEF). “How come there is not a social movement for this?”

Against the backdrop of 20th-Century triumphs in medical research and public health, today’s toll of the young seems especially senseless. In the 50 years since the end of World War II, the proportion of children in the “developing world” who do not survive past their fifth birthday has been slashed by almost two-thirds, to about 100 per 1,000 live births (compared to 10 per 1,000 in the United States).

But recently, experts have been voicing fears that the world may have reached a turning point--one where past achievements in equalizing everyone’s chance for life and health are threatened. “Now far less aid is going to developing countries, and even less is going to the poorest,” said Dr. Peter Poore, senior health adviser at Save the Children-U.K. “All evidence suggests that the gains made during the past decade in reducing child mortality are slowing down, and in some cases being reversed.”

In Nigeria, Africa’s most populous country, child immunizations for a dozen highly communicable diseases, including measles, are dropping, from 80% to as low as 20%, Poore said.

Malnourished Youngsters

India is home to more malnourished youngsters than any other country: 75 million children younger than 5, reported a UNICEF survey released last month. But because of back-to-back cuts in funding for the U.S. Agency for International Development, the Atlanta-based relief agency CARE says it must scale back its supplementary feeding program for mothers and children. CARE-India supplied corn-soya porridge and vegetable oil to 8.5 million women and children two years ago but now can feed only 6.6 million. It is closing operations in three states to compensate for trimmed U.S. AID funds.

“I guess it’s hard to justify to the average American who is faced with the question, ‘Am I going to have health insurance next month?’ spending money to save lives or build up a health system in another country. That’s influencing congressional funding,” said Gita Pillai, CARE-India’s director of nutrition and health.

Long-running, apparently insoluble human tragedies such as those in Somalia and Rwanda, coupled with the economic difficulties experienced by many of the world’s richer countries, from Japan to the United States, may be engendering global “compassion fatigue.”

UNICEF--with a $1-billion core budget, a reputation for effective, goal-directed programs and celebrity “goodwill ambassadors” such as Roger Moore, Harry Belafonte and Peter Ustinov--has not felt any waning in government or private support, said Eva Jespersen of the group’s New York funding office.

But others aren’t so lucky.

Canadian bilateral aid to poor countries has been trimmed by a third. Britain is slicing its assistance to Africa by $24 million, to $407 million in 1996-97. And according to Washington insiders, bilateral American development aid to Africa--now the most hazardous place on Earth to be a child but a region where few vital U.S. interests are at stake--is likely to be sliced 18% to 20% by Congress.

“Still we have poor countries in our region, and the donors are cutting back,” complained Dr. Anton Fric, a WHO medical officer from the Czech Republic working in the agency’s child immunization program in Southeast Asia and the subcontinent.

The bold, perhaps naive dream has been that all children are entitled to an equal chance at survival, without regard to their land of birth. Seventeen years ago, at an international conference co-sponsored by WHO and UNICEF in Almaty, capital of the then-Soviet Central Asian republic of Kazakhstan, officials endorsed the goal of “health for all” by 2000.

It would be wrong to claim that little has been accomplished since. UNICEF estimates that 2.5 million fewer children will die next year than in 1990 thanks to global immunization campaigns against polio, measles and other child killers and cripplers; increasing use of oral rehydration therapy for diarrhea; promotion of breast-feeding, and other worldwide programs. In India, an immunization program launched a decade ago by the late Prime Minister Rajiv Gandhi may be saving up to 1 million lives a year once forfeited to measles, whooping cough, diphtheria, polio, tuberculosis and neonatal tetanus.

So there is good news, even if some critics charge that the encouraging statistics are inflated.

But even the most cheerful figures can’t mask another, troubling trend: Despite the vision put into words by the conference in Almaty, inequities in health and access to care appear to be growing. “Who are the people who are now the sickest? It’s obviously and clearly the poor,” said Dr. Mira Shiva, director of policy for the Voluntary Health Assn. of India.

True enough, in WHO’s first annual checkup of the human race, Dr. Hiroshi Nakajima of Japan--the Geneva-based U.N. agency’s director general--concluded this year that the gaps between rich and poor are widening. Though infant mortality fell by 25% and overall life expectancy increased by more than four years to about 65, between 1980 and 1993 many disparities worsened between the better-off and the poorest countries of the Third World.

“There are already worrying increases in cholera, tuberculosis and plague--all diseases closely linked to poverty--while immunization rates against potentially fatal diseases are beginning to stumble backward in some countries,” Nakajima wrote.

“Growing inequity is literally a matter of life and death for many millions of people, since the poor pay the price of social inequality with their health.”

At Risk in Africa

In the cradle of the human race, the African lands south of the Sahara, the lives of the young are in greatest jeopardy. Cycles of famine and civil war, along with corrupt governments and attendant political instability, compound other factors that gnaw at a child’s chances for survival: poverty, malnutrition, poor hygiene, tropical environments favorable to disease. Malaria, meningitis and parasites are added local threats.

In four countries--Niger, Mali, Guinea and Malawi--more than half the married women have lost at least one child. In UNICEF’s worldwide ranking of mortality among those younger than 5, no fewer than 18 of the 20 worst-performing countries are in Africa. Statistically, babies born in sparsely populated Niger are the unluckiest of all: Almost a third do not live past their fifth birthday.

On Africa’s Horn, another nightmare scenario seems to be fast coming true, one that etches the poignant contrasts between poor and rich nations. On March 3, U.N. peacekeepers bade good riddance to chaos- and famine-racked Somalia, leaving rival clans to squabble for power there. A measles epidemic caused thousands of children to die in 1991-92.

A replay appears to have begun; aid workers last month reported hundreds of measles cases among newborns to 2-year-olds. The outside world, which poured at least $2 billion into the failed U.S.-led peacekeeping mission in Somalia, seems in no hurry to sink more money into humanitarian operations.

But UNICEF has calculated that for $25 billion more each year, child malnutrition such as that now fast resurfacing in Somalia could be halved, major childhood diseases tamed, deaths for those younger than 5 slashed annually by 4 million, and safe water and sanitation supplied to all communities.

That is a huge sum. Consider, though: It is half of the about $50 billion that Europeans spend each year on cigarettes, $6 billion less than what Americans pay for beer.

No Magic

But the generosity of outsiders, even if it could be revitalized, cannot do magic. Many developing countries desperately need to do more.

Pakistan, for example, spends 31% of its budget on its armed forces--and 1% on health care. (America, by comparison, spends 18% of its federal budget on defense and 16% on two health programs alone, Medicare and Medicaid.) Pakistan, which has gone to war three times with India, has its own nuclear-weapons program--and one of the highest child-death rates in Asia. Of each 1,000 infants, 137 will die before age 5.

The results of such scanty budget allocations for public health may be hard to visualize, but coping with them is the daily plight of health professionals throughout the developing world.

Dr. Abdul Wahab Achakzai is medical officer at the Civil Hospital in Chaman, a poor and dusty Pakistani bazaar town. Each day, 700 to 800 children and adults stream into his flyblown establishment near the Afghan border for treatment of diseases ranging from malaria to tuberculosis.

“The government gives us 120 rupees”--less than $4, Achakzai told a visitor one afternoon as he examined a shivering 5-year-old girl who he suspected had been bitten by a mosquito carrying vivax malaria. Less than $4. That’s not per patient. That’s the hospital’s daily subsidy, Achakzai said.

In Mozambique, nearly twice the size of California and where a decade-long guerrilla struggle against Portugal was followed by 16 years of civil war, 100% of the health budget is provided by foreign donors (and 164 of each 1,000 live newborns don’t make it to their first birthday).

In two dozen countries of the Third World, governments that have money to buy Mercedes limousines for their ministers or generals spend less than $5 per inhabitant on health per year. Hundreds of millions in Asia, Africa and Latin America live under leaders whose budgets for health total less than $12 per man, woman and child--the minimum fixed by the World Bank for essential health services.

In recent decades, billions in public and private money have been spent to better children’s chances for survival, and some of the keenest minds in medicine and science have toiled on vanquishing Third World health dangers such as guinea worm and onchocerciasis, or river blindness.

In Bangladesh, just one international donor with deep pockets, the World Bank, will spend about $197 million on health in the five years ending in 1996. “We’re getting somewhere,” Dr. Fric of WHO maintains. “You can already see 90% of reductions in measles cases.”

But the glass is achingly half-full and may not be getting fuller. WHO estimates that annually, about 3 million newborns in the developing world die in the first week of life. Those who survive often face a brutal, short existence.

Low Birth Weights

In the crowded hothouse that is Bangladesh, more than 40% of newborns weigh less than 5 pounds, 8 ounces--”low weight” by international standards. In the low-lying land swept by floods and killer cyclones, malnutrition is so endemic that over the past 15 years, researchers have found that Bangladeshis, on average, have shrunk an inch in height. “Our children can survive. But with such a population in the future, what will we do?” asked Jyotsnamoy Chakraborty, manager of health services at a rural research clinic and hospital in Matlab.

Considering that cures for many of today’s most lethal child-killers are often cheaper than a pack of chewing gum, it is heartbreaking to witness how often young lives are forfeited, as happened this summer in the scrubland of northwestern India. A diarrhea epidemic broke out in the village of Haspurkalan, where 100 families scratch out a living by coaxing subsistence crops of wheat and millet from the sandy soil.

The monsoons probably washed fecal matter from the fields, which villagers use as an outdoor toilet, into Haspurkalan’s two open wells. Three children fell ill and died.

On Aug. 30, 2-year-old Anju began vomiting and suffering diarrhea. Because of the flooding, her parents could not take her to the nearest hospital, five miles away. Early the next day, they did manage to get through to the hospital at Khairtal. The girl, dangerously dehydrated and depleted of nutrients, died soon after admission.

Her father, Dharamveer, plunged into grief.

It was then that a doctor approached him and put something in the bearded 26-year-old’s callused hands: a packet of oral rehydration salts, which the peasant man had never heard of. Had he known, he could have saved Anju’s life by plunking down as little as five rupees--less than 15 cents--at a pharmacists’s shop in town.

Times staff writers John Balzar in Nairobi, Kenya, and Juanita Darling in San Salvador and special correspondent Amitabh Sharma in New Delhi contributed to this report.

Next: The world’s checkered record in saving children’s lives.

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Regional look at access to safe water (% of population)

Latin America and Caribbean: 80%

Middle East and N. Africa: 77%

Sub-Saharan Africa: 42%

South Asia: 77%

East Asia Pacific: 77%

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Least developed countries: 49%

Developing countries: 69%

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Hardest-hit countries (% of population with access to safe water)

1) Sierra Leone: 3%

2) Afghanistan: 12%

3) Central African Republic: 18%

4) Bhutan: 21%

5) Chad: 24%

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Child mortality in developing countries (among children younger that 5)

Respiratory infections: 26%

Diarrhea: 23%

Measles-related: 10%

Malaria-related: 8%

AIDS: 1%

Other: 32%

12.2 million total deaths. 1993 figures

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Impact in America

Diarrhea among children under 5 annually accounts for:

20 million to 35 million episodes affecting 16.5 million children

3 million doctor visits

11% of hospitalizations of children this age (220,000)

300 to 500 deaths

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Spending

$500 million for diarrhea-related hospitalizations

$300 million for doctor visits

Sources: World Health Organization, Journal of Pediatrics

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How to Help

More than 100 American charities try to help children in the developing world. Many are members of InterAction, a coalition of emergency relief and development groups that have agreed to abide by ethical standards to ensure accountability to donors, professional competence and quality of service. This is just a sampling of U.S. groups that focus much of their work and feeding and caring for youngsters around the globe:

CATHOLIC RELIEF SERVICES*

800-235-2772

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CARE*

800-521-CARE

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CHILDREN INTERNATIONAL

800-888-3089

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CHRISTIAN CHILDREN’S FUND*

804-756-2700

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COMPASSION INTERNATIONAL

800-336-7676

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CHILDREACH*

800-444-7918

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FOOD FOR THE HUNGRY*

800-2-HUNGER

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FREEDOM FROM HUNGER*

916-758-6200

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SAVE THE CHILDREN*

800-243-5075

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U.S. COMMITTEE FOR UNICEF*

800-FOR-KIDS

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WORLD VISION*

800-423-4200

* Member, InterAction

For a list of more agencies or for further information: InterAction, 202-667-8227, ext. 132. The group also has a World Wide Web page at https://www.interaction.org/ia//

Source: InterAction