COLUMN ONE : Fighting to Save the Children : Relief workers use savvy and guts to help remote villagers keep their youngsters alive. But some programs are dogged by controversy over outside intentions and internal corruption.

The Shipibo Indians live two days’ journey from the nearest electric light switch in a world imbued with mysticism. Here, they believe, pink dolphins living in the Pisqui River father albino babies.

Childbirth, women insist, is painless--without tears or screams. Floresta Alomias has given birth nine times in the traditional way: squatting, holding on to a post, with her mother and a midwife present for moral support.

But the magic in this verdant swath of Amazon jungle seems to run out once the children are born. One in five dies before reaching age 1--one of the highest infant mortality rates anywhere.

The causes are not rare genetic disorders or exotic diseases carried by one of the many bloodsucking insects that share their jungle. More than half the deaths of Shipibo children younger than 5 are caused by diarrhea. Others succumb to respiratory infections, tetanus and kidney failure.

“We could only buy medicine when the traders came,” explains Curtita Alomias, a 65-year-old great-grandmother who had a dozen children but lost six to disease. “Before, there was no cure. It was considered normal.”

It was normal. The woman spinning cotton into thread now speaks in the past tense, because since February, the relief agency Doctors Without Borders has been in this steamy patch of rain forest, working to save the children of the Pisqui River.

These days, Dr. Maria Luisa Larive and two nurses ply the river at the headwaters of the Amazon in a peque-peque-- a canoe equipped with a 30-horsepower outboard motor--teaching home remedies and tips on disease prevention, such as boiling water and covering pots of food.

They have begun a five-year program to train at least one person in each of 21 riverside villages in preventive medicine and first aid and to supply them with a small stock of simple, affordable medicines.

With an annual budget of $215,000, or $2.35 a week per child, this program is far cheaper than the Spanish organization’s emergency rescue missions to the civil war-torn former Soviet republic of Georgia or crisis-plagued nations in Africa.

Nevertheless, Tomas Padron, coordinator of the Peru project, must painstakingly stitch small grants together to keep the program going.

“This is not glamorous, like an emergency program,” Padron explains. “It is a long process.”

Progress Uneven, Fragile

Padron’s words could well summarize the sometimes inspiring, dismaying, often controversial and disputed results of efforts to save the lives of the world’s youngest human inhabitants.

In the five years since the United Nations World Summit for Children assembled 71 heads of state and government in New York, malnutrition has been reduced, deaths from measles have plummeted by a reported 80% and oral rehydration therapy is saving more than 1 million children with diarrhea each year.

“I am sure the day is not far off when we will be at par with the West,” predicts Dr. Kamlesh Chopra, chief of pediatrics at the 1,500-bed Lok Nayak Hospital in New Delhi, who is witnessing a dramatic decrease in juvenile diarrhea fatalities. But then, she adds, “it might take us 100 years.”

UNICEF, the United Nations Children’s Fund, estimates that, because of generalized advances in public health, hygiene and education worldwide, 2.5 million fewer children will die next year than in 1990. But impressive as such progress is, it is uneven, notoriously fragile--and, some claim, at least in part a mirage.

The combat against pneumonia, now the world’s single largest killer of children, has fallen far behind the goals set at the 1990 summit, despite a low-cost strategy for administering antibiotics developed by the World Health Organization. Unless large-scale national programs are implemented, UNICEF now warns, in the 1990s, 30 million children younger than 5 will die of pneumonia--more than the combined infant populations of the United States and Canada.

Latter-Day Schweitzers

In a recent bulletin, WHO reported that, in poorer countries, 12.2 million children younger than 5, or more than five times the number of infants and preschoolers in California, die every year--in most cases, from easily preventable causes.

“I blame the countries where this occurs as much as the international development community,” said Dr. Demissie Habte, an Ethiopian pediatrician who heads the International Center for Diarrheal Disease Research in Bangladesh, which won fame for its groundbreaking work in treating one of childhood’s deadliest enemies. “For spending their money on a lot of useless things like arms, I blame Third World countries for creating havoc.

“On the other hand, the new sense of isolationism in the West is very damaging. The trend of ‘donor fatigue’ is almost universal, though the loudest noises come from the U.S.”

Why is not more being done? First, to save and prolong children’s lives in Asia, Africa and the Americas, it takes not just large sums and medical savvy but also courage and stamina. Southern Sudan, for instance, has been embroiled in civil war for 29 of its 39 years of independence. In an expanse the size of Britain and Germany combined, there are six miles of paved road. About 50 teams of a U.N.-coordinated relief effort roam this African country, hiding from bandits, looking for breaks in the fighting, to bring medicine, food and other aid to civilians. In such conditions, U.N. Operation Lifeline Sudan is managing to provide “relative stable health care” to 190,000 of the estimated 830,000 children--a heroic effort.

But, sadly, it is patchy and incomplete. So far, only 40,000 children have been vaccinated against measles. “This is not a year to talk of increasing achievements,” says Lifeline evaluation officer Kate Alley.

In the remote reaches of the Pisqui River, Larive, 29, a general practitioner from Seville who has come to help the Shipibo, has been given a new name by her grateful hosts: Roningate-- “The River Snake Who Protects Us.”

Still, it takes a lot of trust to convince mothers that the cures taught by Larive work. Others, after watching so many children die, are skeptical that anything can save them.

“This is a long-term process,” says the Spanish physician. “We have to live with them and show them by doing: washing our hands, boiling water even though it does not taste good, drying the children off after they swim in the river. They will notice that these habits benefit them, that their children get sick less often.”

Such tales of latter-day Albert Schweitzers braving disease and discomfort to save boys and girls in the remotest reaches of the Third World can be told by the thousands and are one of many reasons not to give up hope. But they are just part of a complex picture.

What insiders term the “development community” is a big, multifaceted and often squabbling gaggle of U.N. agencies, government departments, super-national bureaucracies like the World Bank and charitable non-governmental organizations, or NGOs, like Doctors Without Borders.

‘Donors Can Be Fickle’

Such groups collect and expend money to do good--but do they always? It depends on the view. “Donors can be very fickle,” says Dr. Peter Poore, senior adviser at London-based Save the Children-United Kingdom. “They have their own agenda to answer to.”

Take smallpox eradication, which Newsweek magazine this autumn proposed as the greatest achievement of the U.N. system in its half-century of existence. Wiping out the acutely infectious virus has saved Americans $1 billion in unnecessary doctor visits and shots, according to one printed estimate. Who could criticize vanquishing a microbe so devastating that historians believe it was one of the main reasons European settlers conquered North America and the more vulnerable American Indians?

Some public health professionals, it turns out.

Dr. Debabar Banerji, founder of the Department of Community Health and Social Medicine at New Delhi’s Jawaharlal Nehru University, is one vocal critic. He claims money spent stamping out the virus in his country could have been better used to deal with more widespread problems: malnutrition, women’s health woes, diarrhea. “Do you know how many people we had dying of smallpox? Three to four thousand [annually],” he says. “This is peanuts for us.”

What seems like another can’t-lose health issue--UNICEF’s Universal Child Immunization Program, launched in 1985--has also come under fire. Four years ago, UNICEF announced, more than 100 million children younger than 1, or a global average of 80% of newborns, had been inoculated against six highly contagious diseases: measles, diphtheria, whooping cough, tetanus, polio and tuberculosis.

From the grasslands of East Africa to the fishing villages of Bengal, UNICEF claims, the lives of 3 million boys and girls are being saved every year.

It sounds wonderful. But, some groups report, after a peak reached at the beginning of the decade, immunization levels are falling in some countries and funding is drying up. Universal immunization was like reaching the moon: Once the job was done, some lost interest.

“After the year 1990, the donors felt, we’ve done that, now it’s the individual countries’ turn,” says Poore. He stresses that he does not wish to revive Save the Children’s dispute with UNICEF at a time when, he says, shrinking funds for Third World health, and not how the money is allocated, have become the No. 1 problem.

Even when vaccines have been given, they are sometimes ineffective, leading many to wonder just how meaningful are the statistics trumpeted by UNICEF and WHO. In the exercise room of St. Mary’s Poly Clinic northeast of the Indian city of Lucknow, Shailendra Kumar was struggling one morning last month to pedal a stationary bicycle welded from sections of yellow pipe. In mid-August, the 4-year-old developed bulbar polio, a particularly virulent variety that attacks the brain stem just above the spinal cord, injuring nerve centers that control swallowing and talking.

It wasn’t supposed to happen.

“My son had the polio drops twice at the state-run primary health center, but he still had a severe attack,” Jagdeo Kumar, who works as a sharecropper, recalled. “Within 10 days, both his legs and hands became senseless.”

Health officials in Uttar Pradesh, India’s most populous state, claim a polio immunization rate of no lower than 95% in Lucknow and vicinity. But Dr. Varkey Valladiyil Brigeetha, moving spirit behind the 45-bed St. Mary’s Clinic, grimaced when the numbers were mentioned. “Everybody knows [Uttar Pradesh] Health Department statistics carry no value,” she said. “In our hospital, 50% of the cases we admit have had the polio drops.”

Vaccines Spoiled by Climate

In October, a study funded by the U.S. Agency for International Development and coordinated by the International Institute for Population Sciences in Bombay threw another bomb at UNICEF’s claims. It found that only 35% of Indian children between 23 months and 12 years were fully immunized against tuberculosis, diphtheria, whooping cough, tetanus, polio and measles and that no fewer than 30% of children in that age group have never been vaccinated.

“We’re talking of India. But UNICEF isn’t. They’re talking globally,” says Banerji, 65. He estimates that half of the vaccines administered in north India are spoiled, and, therefore, useless. The Achilles’ heel of universal immunization plans, he contends, is that the globally designed program requires something impossible to realize in the context of India’s climate, poverty and vastness: a secure “cold chain” to maintain imported vaccines at a constant temperature of 37 degrees Fahrenheit until they are administered.

Predictably, UNICEF vociferously denies that it foists solutions on anyone. “We have no global agenda. What we have is management by objective,” said Dr. Monica Sharma, an Indian physician who works as a senior adviser in the Child Survival Unit at UNICEF headquarters in New York.

It is undeniable, however, that the best wishes and plans of outsiders have been doomed because somebody failed to take into account local conditions or beliefs. In 1990-93, UNICEF paid to build sturdy, telephone-booth-like latrines of brick and concrete in its “model” village of Basra in the Indian state of Rajasthan. The outhouses were meant to improve hygiene. But villagers use them mostly to store dried cow-dung cakes used for fuel. As before, most villagers simply prefer to use their fields as latrines.

This year, water pumps were installed by relief agencies along the arid northern frontier of Kenya. Clean water is the greatest need of the nomadic Samburu people, cousins of the storied Masai. But the young moran , or warriors, have taken a liking to decorating their walking sticks with nuts and bolts. The unplanned-for result--many dismantled pumps.

Chastened by knowledge of such fiascoes, the Doctors Without Borders team in Peru is now hesitating to impose the use of latrines among the Shipibo, though that is normally a rudimentary step in halting the spread of infectious diseases. “Each Shipibo has a private spot that he uses each day,” explains nurse Pilar Caminero. “They think we are absolute pigs to all use the same toilet.”

Outsiders are waiting to see what might happen during heavy rains, when the Pisqui River can rise 50 feet and flood its banks. In those conditions, a latrine could become a source of contamination. “We are not trying to impose our customs but to help them recover their own,” Padron insists.

Of course, many developing countries seeking reasons for their high child illness and death rates can find answers much closer to home, if they have the courage and honesty to look.

Kenya, independent and stable since 1963, is home to one of East Africa’s most educated populations and hopeful economies. But Health Minister Joshua Angatia now concedes his department is filled with “saboteurs and thieves.” In July, news surfaced that patients in public hospitals were being left to die because government health workers had looted at least $13 million in incoming medicines and supplies for resale. Widespread corruption in public works denies tens of thousands of families clean water. East of Nairobi, the capital, an epidemic of dysentery recently killed 20 people.

In India, now in the fifth year of market-oriented economic reforms, consumers with disposable rupees have more choices than ever: Coca-Cola, Pepsi and local bubbly drinks like Thums Up, for example. But 43% of the people, or more than 387 million men, women and children, still don’t have access to clean water, a fundamental requirement for good health. The Asian giant, which accounts for a third of the world’s child deaths, even gave up this year on its pledge of providing “health for all” by 2000.

“Neither people nor history will forgive us,” Health and Family Welfare Minister A. R. Antulay said.

India’s doctors and pharmaceutical companies also are fiercely criticized by health activists.

Instead of promoting cheap, homemade varieties of oral rehydration solution, like a gruel made from rice, the health industry would rather sell an estimated $7.6 million worth of sachets of electrolytic powder.

Those packets are even made available by the government free in many cases, but some physicians refuse to hand them out “because it doesn’t bring them any returns,” admits Dr. Jagdish Chand Sobti, honorary general secretary of the Indian Medical Assn. Meanwhile, diarrheal diseases kill 700,000 children in India each year.

One Little Patient at a Time

All this is far away, indeed, from the banks of the Pisqui River. But it is in spots like this where the struggle to save the children will be won or lost. As Larive of Doctors Without Borders talks through an interpreter, Floresta Alomias, the Shipibo woman, sits on the platform floor that prevents her hut from flooding when the river rises. Four of her nine children died as infants. Now, her 9-month-old daughter, Delbi, has diarrhea. She is trying to comfort the sobbing child as she answers Larive’s questions.

“Tita,” the doctor asks, using the title of respect for married women, “where is the saline solution?” the home brew of boiled water, sugar, salt and lemon juice used in the rain forest to rehydrate and restore minerals to babies. At a signal from Floresta, a child brings a dented metal pot from a shelf behind her.

“And where is the lid?” After a search, the ill-fitting lid appears. “And the spoon?” The doctor examines the spoon for dirt, then places it over the lid on the pot. “This is how it should go, remember?” she says.

If Alomias remembers, Delbi will get better.

If Larive is lucky, other mothers in Shipibo will notice, and try the cure themselves.

Meanwhile, on this day, much like any other, 33,400 children in the poorer countries of Latin America, Africa and Asia will die from diarrhea, respiratory infections, measles and other easily preventable and curable diseases.

Darling reported from Charasmana, Peru, and Dahlburg from New Delhi. Also contributing were Times staff writer John Balzar in Nairobi and special correspondent Amitabh Sharma in New Delhi.

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Comparing the cost of ‘needs’

Here’s how the cost of meeting basic health and sanitation needs worldwide--$25 billion a year--compares to the costs for some of the industrialized world’s other “needs” (in billions of dollars)

Cigarettes in Europe (per year): $50

Business entertaining in Japan (per year): $35

Beer purchased in the United States (per year): $31

Russia’s 1992 G7 aid package: $27

Proposed new Hong Kong airport: $23

Meeting basic needs (per year): $25

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Deaths per 1,000 live births, 1993

Latin America and Caribbean: 48

Sub-Saharan Africa: 179

Middle East and N. Africa: 70

South Asia: 127

East Asia, Pacific: 56

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Mortality rates, children younger than 5

Deaths per 1,000 live births have decreased over the last four decades.

Total mortality rate worldwide

1960: 216

1970: 168

1980: 138

1990: 107

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Levels of malnutrition

Percentage of children younger than 5 who are malnourished.

India: 63%

South Asia: 60%

Developing world: 36%

Sub-Saharan Africa: 31%

East Asia: 26%

Central America-Caribbean: 17%

Latin America: 8%

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Average number of children

The number of births per woman worldwide has declined.

1960: 6.0

1970: 5.7

1980: 4.4

1990: 3.8

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Top givers

*--*

Global Aid for 1993 Aid per (billions) capita Japan $11.3 $90 U.S. $9.7 $38 France $7.9 $138 Germany $7.0 $86 Italy $3.0 $53 Britain $2.9 $50 Netherlands $2.5 $165 Canada $2.4 $82 Sweden $1.8 $203 Denmark $1.3 $259

*--*

Sources: U.N. Population Division, UNICEF, World Bank

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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*

209 W. Fayette St.

Baltimore, Md. 21201

800-235-2772

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CARE*

151 Ellis St. NE

Atlanta, Ga. 30303

800-521-CARE

****

CHILDREN INTERNATIONAL

P.O. Box 419055

Kansas City, Mo. 64141

800-888-3089

****

CHRISTIAN CHILDREN’S FUND*

2821 Emerywood Pkwy.

Richmond, Va. 23294

804-756-2700

****

COMPASSION INTERNATIONAL

Colorado Springs, Colo. 80997

800-336-7676

****

CHILDREACH*

155 Plan Way

Warwick, R.I. 02886

800-444-7918

****

FOOD FOR THE HUNGRY*

7729 E. Greenway Rd.

Scottsdale, Ariz. 85260

800-2-HUNGER

****

FREEDOM FROM HUNGER*

P.O. Box 2000

Davis, Calif. 95617

916-758-6200

****

SAVE THE CHILDREN*

54 Wilton Rd.

P.O. Box 940

Westport, Conn. 06881-9948

800-243-5075

****

U.S. COMMITTEE FOR UNICEF*

333 E. 38th St.

New York, N.Y. 10016

800-FOR-KIDS

****

WORLD VISION*

P.O. Box 70003

Tacoma, Wash. 98481-0003

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