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The Progress of Nations 1997

The day will come  when nations will be judged  not by their
military or economic strength,  nor by the splendour of
their capital  cities and public buildings,  but by the
well-being of their peoples:  by their levels of health,
nutrition and education; by their opportunities to earn a
fair reward for their labours; by their ability to
participate in the decisions that affect their lives; by the
respect that is shown for their civil and political
liberties;  by the provision that is made for those who are
vulnerable and disadvantaged;  and by the protection that is
afforded to the  growing minds and bodies of their children.
The Progress of Nations, published annually  by the United
Nations Childrens Fund, is  a contribution towards that day.

                           * * * *
1. Foreword by Kofi A. Anan, Secretary-General United Nations

2. Charting progress for children:  Introduction by Carol Bellamy,
   UNICEF Executive Director

3. Water and Sanitation
   Commentary - The Sanitation gap: Development's deadly menace
   3.1 Sanitation League Table
   3.2 Water/sanitation gap widening
   3.3 79% of all guinea worm cases occurring in Sudan
   3.4 Grading school sanitation: Few high marks
   3.5 Making ORT a household habit

4. Nutrition 
   Commentary - Putting babies before business
   4.1 Nutrition League Table
   4.2 Exclusive breastfeeding: A chance for survival
   4.3 One in five babies too small at birth
   4.4 Stunting: A scar and a wound
   4.5 Slow starters catching up in salt iodization

5. Health
   Commentary - Fighting AIDS together
   5.1 Gauging AIDS' terrible toll
   5.2 Health League Table
   5.3 Pneumonia: K=Little progress on a big killer
   5.4 52 countries falling short on immunization goal for DPT
   5.5 Neonatal deaths: 5 million each year
   5.6 Malaria's death toll: A child every 30 seconds

6. Education
   Commentary - Quality education: One answer for many
   6.1 Doing more with less
   6.2 Girls' education: Commitment or neglect?
   6.3 Maths and science: Some developing countries score high
   6.4 Do teachers make the grade?
   6.5 Rural kids short-changed

7. Women
   Commentary - The intolerable status quo: Violence against
                women and girls
   7.1 Women's League Table
   7.2 Outlawing violence against women: A first step
   7.3 Risk of death in childbirth can be as high as 1 in 7
   7.4 A bill of rights for women, but with reservations
   7.5 Help wanted: Skilled birth attendants

8. Special Protections
   Commentary - No age of innocence: Justice for children
   8.1 Old enough to be a criminal?
   8.2 Over 7 million children are refugees
   8.3 Hidden killers
   8.4 The cost of war: Billions for development diverted to

9. Industrialized Countries
   Commentary - Healthy cities, healthy children
   9.1 Youth unemployment rate highest in Spain, lowest in Austria
       and Switzerland
   9.2 Teens at risk: Drinking and bullying
   9.3 Sharing the wealth? Aid at lowest level in 45 years

10 Statistical Tables
    Social Indicators for Less Populous Countries

   Statistical Profiles for 149 countries
    The age of the data
    Statistical tables are available at the UNICEF website
                      * * * *


Putting babies before business

The Right Reverend Simon Barrington-Ward*

For babies everywhere, the benefits of breastfeeding are
undisputed. But for babies in developing nations,
breastfeeding is imperative: Their very survival depends on
the immune-boosting properties of mothers milk. For them,
infant formula is not just inferior; it can cause disease or
even death. Poor families often over-dilute costly formula
with unclean water and mix it in unclean bottles, adding to
the risk. Yet, despite international pleas and a marketing
code agreed to 16 years ago, manufacturers still market infant
formula and other substitutes unethically around the world. It
is time for them to stop.

Not all miracles stand up to scientific scrutiny, but
breastmilk is one that does. It is without doubt one of the
worlds greatest life-savers. The most sophisticated science
has taken a long time to recognize and prove what mothers and
midwives always knew - breastfeeding is best for babies and
there is no substitute of equal value.

Breastmilk is a live and incredibly complex substance,
containing all the nutrients vital for nourishment, as well as
growth factors believed to help in tissue development and
antibodies to fend off infections. It is always at the right
temperature, requires no mixing, sterilization or equipment,
and is safe regardless of the quality and availability of
water. Its composition changes from feeding to feeding, and
even within feedings, and the amount is triggered by the
mothers hormonal response to the needs of the baby.
Breastfeeding encourages bonding between mother and baby and
discourages conception. 

The World Health Organization and UNICEF recommend that babies
be fed breastmilk only - nothing else, not even Water - for
about the first six months of life. Worldwide, reduction of
formula feeding and improved breastfeeding practices could
save an estimated 1.5 million children a year.

So why are only an estimated 44 per cent of infants in the
developing world (even less in the industrialized countries)
exclusively breastfed? One factor has to be the relentless
promotion of breastmilk substitutes. It is no accident that
breastfeeding levels are high in countries like Burundi and
Rwanda, where there is little marketing. 

I am now firmly persuaded that the promotion regularly
practised by the infant formula companies is unethical and
that it flouts the International Code of Marketing of
Breast-milk Substitutes, to which they signed on. In fact,
they helped draft the Code, which seeks to protect
breastfeeding as an unequalled way of providing ideal food for
the healthy growth and development of infants. 

The World Health Assembly adopted the Code in 1981 as a
recommendation to its member States. They in turn are urged to
translate it into national legislation ensuring that
breastmilk substitutes are not marketed or distributed in such
a way as to interfere with the protection, promotion and
support of breastfeeding. 

All along, the industry has insisted that it was
self-monitoring to ensure that its members followed the Code.
The International Baby Food Action Network (IBFAN), a
non-governmental organization, suspected otherwise, and it
doggedly set about to collect evidence. Enough violations of
the Code accumulated to justify a consumer boycott of infant
formula manufacturers. 

Based on IBFANs findings and showing good-faith efforts to be
fair, the groups that imposed the boycott have lifted and then
reinstated it over the years. Currently, church and consumer
groups, businesses and trade unions in 17 countries are active
in the boycott in response to findings by IBFAN.

But rather than redressing the marketing wrongs, the infant
formula manufacturers lobby has wilfully misinterpreted the
Code: Despite the word International in its title, the
manufacturers insist that the Code applies only to developing
countries. They have also hammered away to discredit IBFANs
findings, particularly with governments and United Nations

Cracking the Code

In 1994, the Church of England called for a hiatus in the
slanging match between the manufacturers and IBFAN. The Church
suspended its support for the boycott while it sought
unbiased, independent research into baby formula marketing

To obtain that information, we joined in creating the
Interagency Group on Breastfeeding Monitoring (IGBM), formed
with 27 organizations including Christian Aid, OXFAM, Save the
Children and the UK Committee for UNICEF. Now we have stark
new evidence in the form of a report, Cracking the Code, which
proves that 32 companies, including Gerber, Mead Johnson,
Nestle, Nutricia and Wyeth, have been routinely ignoring the

Cracking the Code reports on a study undertaken between August
and October 1996 in Bangladesh, Poland, South Africa and
Thailand. In each country, the study involved interviews with
800 pregnant women and new mothers and 120 health workers in
40 facilities. The results showed that, among other violations
of the Code, the formula companies have been distributing
marketing literature promoting formula over breastmilk and
giving away formula to maternity hospitals and mothers - from
1 in 12 mothers surveyed in Poland to 1 in 4 in Thailand.

Free samples, especially those handed out by health
professionals, are a particularly insidious form of promotion.
A mother can easily switch from breast to bottle, but from
bottle to breast is another story. After being fed with free
samples of formula even for just a few days, the baby, used to
an artificial teat, is fussy about accepting the breast. While
the baby has been drinking formula, the mother's milk
production has declined. 

Now the worried mother has a cranky and hungry baby on her
hands, and she is convinced she must give up the breast and
use formula for the duration. Rarely are such problems - and
their solutions - explained to women when  gifts' of baby
formula are thrust into their hands. And when a doctor or
nurse is providing the  gift', it carries the health
profession's implicit stamp of approval.

The industry has complained that the IGBM study is biased and
unscientific. This is rubbish. Independent coordinators
supervised the study in each country, and the many
organizations that sponsored it would not have gone through
this exercise without firm assurances that rigorous research
protocols would be observed. 

The Church of England suspended its support of the boycott as
an act of good faith while the study was undertaken. The
industries criticism of the study adds up to this: The
multinationals simply are not about to acknowledge their own
unethical practices in countries that offer promising market

It is now clear to me that the only way to end these practices
is by threatening the commercial interests that drive them.

To concentrate its effectiveness, the consumer boycott has
targeted one company: Nestle. But that is not to suggest that
the others are pure in their motives and actions - quite the
contrary. They go about the same business, obscured in the
shadows, while the light is shined on Nestle. And if the IGBM
had the resources to survey more countries, I have no doubt
that we would find many more companies violating the Code. 

These violations are not innocent; they are wilful. The
companies have a moral obligation to abide by the Code, but
instead they have treated it like something they can ignore
with impunity until they are caught. They bank on the fact
that developing countries do not have the resources to police
the companies. Cracking the Code was our response to this
implied challenge, and I hope it puts the manufacturers on
notice that those countries have allies in the effort to put
babies before business.

The body as a machine

The companies' aggressive efforts to replace something safe
and naturally perfect with a manufactured commodity is a
continuation of a long campaign that began during the
Industrial Revolution. It has its roots in the mechanistic
philosophy that viewed the human body as a machine that could
be rationally managed.
The first breastmilk substitute was sold in the mid-1860s, and
Henri Nestle, a chemist working in Frankfurt, brought his
product to market soon after. Mixing meal and cow's milk in
"correct scientific proportion," he said in 1867, results in
"a food which is all that could be desired." But he was wrong,
along with any number of others who promoted supposedly
"scientific" techniques, such as bloodletting.

The move towards infant formula became epidemic in the
industrialized countries after the Second World War and is
spreading in rapidly urbanizing parts of the developing world.
Despite their claims, though, industry has never developed a
product on a par with breastmilk. In fact, the best that
science has done in this area is to prove that women's bodies
know better than any manufacturer what to feed their babies,
and when.

Of course, the impact of inappropriate infant feeding is
immeasurably greater in developing countries. Lack of safe
water for mixing the formula and contamination of feeding
bottles are the main reasons why formula-fed babies die;
another is that families cannot afford adequate supplies of
formula, so they dilute it too much. 

Compared to babies who are exclusively breastfed, those who
are fed formula have 10 times the risk of incurring bacterial
infections requiring hospitalization, 4 times the risk of
meningitis and 3 to 4 times the risk of developing middle ear
infections and gastroenteritis. 

The risk, though, is not just in the developing world. In
terms of lifelong chronic illness in industrialized countries,
formula-fed babies have increased levels of asthma, allergies,
eczema, diabetes and ulcerative colitis - and 5 to 8 times the
risk of childhood lymphomas. Children who are not breastfed
have lower scores on mental development tests and their vision
is not as sharp. It is all noted in the scientific literature.

No one wants to impose breastfeeding on mothers. When women
have the resources to afford adequate supplies of formula,
safe water and fuel to sterilize bottles and synthetic
nipples, formula may be an appropriate alternative for those
who do not wish to breastfeed. 

Formula is not the optimal choice, however, and women should
be told that. Quite frankly, I question how much true  choice'
is involved when doctors, mothers and all the rest of society
have been inundated with messages that disparage
breastfeeding, in ways both subtle and blatant. 

Some few mothers are unable to lactate, but there would be far
fewer if all mothers were helped to begin breastfeeding
immediately following delivery, rather than having a bottle
thrust right into the baby's mouth.

The industry, along with many women's groups, says infant
formula frees women who work outside the home from the tether
of breastfeeding. That, they argue, is why bottle-feeding
spreads in tandem with urbanization. 

But is bottle-feeding really more convenient than
breastfeeding? Is it easier to buy, prepare, tote, refrigerate
and heat bottles of formula? The perceived inconvenience of
breastfeeding should also be weighed against the later
inconvenience of having to stay at home from work to care for
formula-fed children, who, statistics tell us, are more sickly
than breastfed children.

Employers undoubtedly need to do more to accommodate
breastfeeding mothers, and they should be encouraged by
supportive government policies. Adequate, paid maternity
leave, high-quality infant care at or near the workplace and
facilities to express and store breastmilk would go far to
encourage working mothers to begin breastfeeding and continue
it after returning to work. Given its benefits for babies'
health, it is in employers' interest to support the practice -
to reduce absenteeism.

People in poor countries are often persuaded by advertisements
that bottle-feeding is the modern thing to do. Having lived in
Nigeria and travelled through much of Africa and Asia, I can
report that formula manufacturers regularly use images of
white doctors surrounded by black or Asian babies to promote
their products as being the modern, healthy,  first world' way
to bring up a baby. It is a very potent and persuasive
message, trading on images of modernization.

The true costs of formula

The price of bottle-feeding is an issue for finance ministers
as well as families. From China to Zambia, when developing
countries import breastmilk substitutes, they are exporting
scarce foreign exchange that is desperately needed for other
vital priorities. On top of that, precious health care funds
are spent on illnesses wrought by artificial feeding.

If the 51 per cent of Indian mothers who exclusively
breastfeed were to stop, replacing all their breastmilk with
formula would cost about $2.3 billion. In Indonesia, a study
in the 1980s calculated that mothers produced over 1 billion
litres of breastmilk annually; equivalent supplies of
commercial milk would cost $400 million. Savings in health
costs and reduced fertility rates related to breastfeeding
were estimated to be another $120 million. In Haiti, where
just 3 per cent of infants are exclusively breastfed, infant
formula costs $10 a week, or more than twice a typical income. 

That is why it is so devastating when free samples end and the
mother finds that her milk has diminished. For those who
cannot afford adequate supplies of formula, the temptation to
over-dilute it is enormous.

Compare the cost of formula with the cost of feeding a mother
so that she can properly breastfeed. Ideally, she needs an
additional 500 calories a day above her normal diet, something
easily achieved at far less than the cost of formula. In
India, for example, five days' worth of that extra food costs
less than 15 rupees (45 cents). By comparison, a five-day
supply of formula costs about 130 rupees ($3.70). In the
Philippines, Jose Fabella Hospital saved more than $100,000,
an astounding 8 per cent of its annual budget, within one year
of becoming a baby-friendly hospital, promoting and supporting
exclusive breastfeeding of infants.

The Baby-Friendly Hospital Initiative is one approach to
improving breastfeeding rates. A hospital is designated
 baby-friendly' when staff have agreed not to distribute or
otherwise promote artificial baby milk and to implement
specific steps to support breastfeeding. 

This is an excellent initiative, but it does not protect women
after they go home from the hospital, nor does it protect the
many women in developing countries who give birth at home.
There, messages promoting formula reach them via the media,
formula company sales representatives and the commercial
influence of health care workers through so-called
professional education.

To rein in the multinationals, we need rigorous laws to
enforce the International Code of Marketing of Breast-milk
Substitutes in all countries. Such laws are crucial both to
redress practices that have undermined breastfeeding and to
prevent such practices in countries where commercial pressures
have yet to gain a foothold. Compliance with the Code must be
enforced by committed governments.

Such national laws are not easily enacted. The industry grows
more powerful every day, thanks to economic globalization. Yet
16 countries have managed to achieve full compliance with the
Code, meaning that they have adopted appropriate laws. (See
league table.) Of course, whether those laws are adhered to
completely is another question.

Challenging laws

Not surprisingly, the industry has challenged some of these
new laws in national courts. Their arguments can verge on the
ludicrous: In India, Nestle argued that it could not meet the
law's requirement that a notice about the superiority of
breastmilk appear in a panel at the centre of formula tins -
because one cannot pinpoint the centre on a cylindrical tin!

Legal measures are only a beginning. We also need advocacy
programmes to dispel the myths about breastfeeding. In the
United States, social attitudes are such that mothers who
breastfeed in public places frequently face harassment,
sometimes even by police officers unaware that it is legal to
breastfeed in public. More countries should offer the kind of
explicit support provided by the Canadian province of Quebec,
where women on public assistance who breastfeed receive an
extra $50 per month.

Finally, the industry should ask itself why it continues its
stubborn pursuit of this market, given the cost to its image.
The multinationals seem to believe they can wear down the
opposition, but I have yet to hear IBFAN - or anyone else who
knows the facts - cry  uncle' in this battle to save 1.5
million infant lives each year. Surely profits from synthetic
baby milk cannot be so great that these multinational
companies are willing to endanger their income on other
products by doggedly pursuing unethical marketing strategies
for formula.

Artificial baby milk should not be advertised in any way, and
that must be final. Although there is a place for synthetic
baby formula, that place is behind the chemist's counter.
Women should have to think consciously about their decision to
use formula rather than breastmilk. They are free to decide to
use formula, but that choice must be informed by the truth
about what bottle-feeding will cost them and their babies.   

                         # # # # #

*The Right Reverend Simon Barrington-Ward, Bishop of Coventry,
was until recently chair of the International Development
Affairs Committee of the Church of England's General Synod. 
He represented the Church on the interagency Group on
Breastfeeding Monitoring.  Bishop Simon is a member of the
House of Lords and has served as General Secretary of the
Church Mission Society.  This commentary was written in his
personal capacity.

Nutrition League Table
Protecting Breastfeeding from Unethical Marketing

The first step on the road towards healthy nutrition is
protecting, supporting and promoting breastfeeding. A key
vehicle for that effort is the International Code of
Marketing of Breast-milk Substitutes. Adopted by the World
Health Assembly in 1981, it calls on all countries to
regulate marketing of breastmilk substitutes to prevent
breastfeeding from being undermined

How countries enforce the Code

The International Code of Marketing of Breast-milk
Substitutes aims to promote infant nutrition by protecting
breastfeeding from inappropriate marketing of infant formula
and other breastmilk substitutes. It is a minimum standard,
enforceable through "national legislation, regulations or
other suitable measures." Only countries that have adopted
legally enforceable measures implementing the Code in its
entirety are listed in category 1. Just 16 countries fall
into this category - a disappointing showing considering
that the Code is a minimum standard.

Countries in category 2 have enacted only some of the Code's
provisions. For example, the member States of the European
Union, based on an EU Directive, have adopted legislation
that is weaker than the Code. It provided that legislation
only apply to infant formulas (and not to the wider category
of breastmilk substitutes, bottles and teats) and that
advertising be allowed in baby care and scientific

Category 3 includes countries that have developed voluntary
agreements with manufacturers providing no means of
enforcement. In Australia this approach has proved
reasonably successful. But the widespread violations
reported in South Africa and Thailand (see Commentary) show
the shakiness of such arrangements. Also in category 3 are
countries that have drafted measures or are still examining
how best to implement the Code. Many are from Central and
Eastern Europe and the Commonwealth of Independent States,
where the distribution of breastmilk substitutes was
formerly centrally controlled.

What the table ranks

Level of compliance with the International Code of Marketing
of Breast-milk Substitutes

What the rankings mean

1.  FULL COMPLIANCE: Countries that have enacted legislation
or other legally enforceable measures that implement the
International Code of Marketing of Breast-milk Substitutes
in its entirely, as called upon by the World Health

2.  PARTIAL COMPLIANCE: Countries that have enacted
legislation or other legally enforceable measures
encompassing some of the Code's provisions.  These measures
therefore do not adhere to the Code as a "minimum standard"
as stressed by the World Health Assembly.

3.  SOME ACTION: Countries that have not enacted legislation
or other legally enforceable measures implementing the Code
but are in the process or have taken other measures. 
Examples include voluntary agreements with industry that
regulate all or some of the marketing practices covered by
the Code, drafting of measures to fully or partially
implement it, or establishment of a working group to study
how best to implement it.

4.  NO ACTION: Countries that have taken no steps to
implement the Code.

                           Level of Compliance

Burkina Faso                       1
Cameroon                           1
Madagascar                         1
Tanzania                           1
Benin                              2
Congo, Dem. Rep.                   2
Ethiopia                           2
Guinea                             2
Guinea-Bissau                      2
Mozambique                         2
Nigeria                            2
Senegal                            2
Angola                             3
Botswana                           3
Burundi                            3
Congo                              3
Cote d'Ivoire                      3
Eritrea                            3
Gabon                              3
Gambia                             3
Ghana                              3
Kenya                              3
Lesotho                            3
Malawi                             3
Mali                               3
Mauritania                         3
Mauritius                          3
Namibia                            3
Niger                              3
Rwanda                             3
Sierra Leone                       3
South Africa                       3
Togo                               3
Uganda                             3
Zambia                             3
Zimbabwe                           3
Central African Rep.               4
Chad                               4
Somalia                            4
Liberia                      No data


                           Level of Compliance
Iran                               1
Lebanon                            1
Algeria                            2
Israel                             2
Saudi Arabia                       2
Tunisia                            2
Turkey                             2
United Arab Emirates               2
Yemen                              2
Egypt                              3
Iraq                               3
Jordan                             3
Kuwait                             3
Libya                              3
Morocco                            3
Oman                               3
Sudan                              3
Syria                              3


                           Level of Compliance

Armenia                            3
Georgia                            3
Kazakhstan                         4
Afghanistan                  No data
Azerbaijan                   No data
Kyrgyzstan                   No data
Tajikistan                   No data
Turkmenistan                 No data
Uzbekistan                   No data

                           Level of Compliance  

India                              1
Nepal                              1
Philippines                        1
Sri Lanka                          1
Bangladesh                         2
China                              2
Indonesia                          2
Japan                              2
Lao Rep.                           2
Mongolia                           2
Papua New Guinea                   2
Viet Nam                           2
Australia                          3
Bhutan                             3
Cambodia                           3
Korea, Rep.                        3
Malaysia                           3
Myanmar                            3
New Zealand                        3
Pakistan                           3
Singapore                          3
Thailand                           3
Korea, Dem.                  No data    

                           Level of Compliance

Brazil                             1
Costa Rica                         1
Dominican Rep.                     1
Guatemala                          1
Panama                             1
Peru                               1
Canada                             2
Chile                              2
Colombia                           2
Cuba                               2
Mexico                             2
Argentina                          3
Bolivia                            3
Ecuador                            3
El Salvador                        3
Haiti                              3
Honduras                           3
Jamaica                            3
Nicaragua                          3
Paraguay                           3
Trinidad and Tobago                3
Uruguay                            3
Venezuela                          3
United States                      4


                           Level of Compliance

Austria                            2    
Belgium                            2    
Denmark                            2    
Finland                            2    
France                             2    
Germany                            2    
Greece                             2    
Hungary                            2    
Ireland                            2    
Italy                              2    
Netherlands                        2    
Norway                             2    
Portugal                           2    
Spain                              2    
United Kingdom                     2    
Albania                            3    
Belarus                            3    
Czech Rep.                         3    
Latvia                             3    
Lithuania                          3    
Poland                             3    
Russian Fed.                       3    
Slovakia                           3    
Sweden                             3    
Switzerland                        3    
TFYR Macedonia*                    3    
Croatia                            4    
Estonia                            4    
Moldova, Rep of                    4    
Romania                            4    
Bosnia/Herzegovina           No data    
Bulgaria                     No data
Slovenia                     No data
Ukraine                      No data
Yugoslavia, Fed Rep.         No data
*The Former Yugoslav Republic of Macedonia, subsequently
referred to as TFYR Macedonia.        
Source: International Code Documentation Centre, forthcoming
Code Handbook, and information from UNICEF field offices,

Progress and Disparity

Exclusive breastfeeding:
A chance for survival

The lives of almost 1.5 million infants could be saved every
year if for the first six months of life they were
exclusively breastfed. That means nothing but breastmilk -
no solids, no other liquids, not even water. 

Data from 69 developing countries, including new estimates
from 40 countries since last years report, show that half of
them have exclusive breastfeeding rates below 25%, with 14
countries at 10% or less. In only 15 countries are 50% or
more of the infants exclusively breastfed.

The good news is that the number of countries gathering data
has more than doubled since 1993, when only 32 developing
countries had data on breastfeeding.

For optimal nutrition and protection against disease,
exclusive breastfeeding is recommended. After the first six
months of life, to ensure their healthy development and
survival, babies should be given nutritious food together
with breastmilk. They also need good care and access to
health services. 

10% and under 
Developing countries with exclusive 
breastfeeding rates of 10% or less

Niger                        1
Nigeria                      2
Angola                       3
Cote d'Ivoire                3
Haiti                        3
Central African Rep.         4
Thailand                     4
Cameroon                     7
Paraguay                     7
Maldives                     8
Senegal                      9
Dominican Rep.              10
Togo                        10
Trinidad/Tobago             10

50% and over
Developing countries with exclusive 
breastfeeding rates of 50% or more

Rwanda                      90
Burundi                     89
Ethiopia                    74
Tanzania                    73
Uganda                      70
Egypt                       68
Eritrea                     65
China                       64
Mauritania                  60
Bangladesh                  54
Turkmenistan                54
Bolivia                     53
Iran                        53
India                       51
Guatemala                   50
Data refer to infants under four months of age.

Sources:  DHS, MCS and other nationwide surveys (1987-1996).

Progress and Disparity

One in five babies too small at birth

One in five babies born in developing countries weighs less
than the standard for a healthy-sized baby: 2.5 kg (about 5.5
pounds). The four countries with the highest rates of
underweight births - Bangladesh, India, Pakistan and Sri Lanka
- are all in South Asia. It is also the region with the
highest rates of child malnutrition, underscoring the fact
that low-birthweight babies are more susceptible to disease
and tend to grow up malnourished.

Low birthweight is a major factor in the global total of more
than 5 million yearly neonatal deaths. In developing
countries, low birthweight usually results from maternal

Some developing countries - including Argentina, Chile, Costa
Rica, Ghana, Jordan, Kuwait, Mongolia, Paraguay, Saudi Arabia,
Singapore, Turkmenistan and the United Arab Emirates - have
reduced low-weight births to levels equal to or lower than
those of industrialized countries.

From age 1 to 3, children born underweight face increased risk
of seizures, blindness and deafness, cerebral palsy and mental
retardation. Low birthweight is also linked to a small
impairment in cognitive development.

Most data on underweight births come from hospital records,
leaving out the many babies born at home. How this factor
skews the data is uncertain. A hospital birth may indicate
higher income and therefore better nutrition, or it could
indicate a higher-risk birth, possibly skewing the data
towards lower birthweight. 

15% or more
Developing countries with 15% or more low-birthweight babies,
and their rate of institutional births
                          %              % low-
                    institutional        birthweight
                       births            babies
Bangladesh                5                50
India                    26                33
Pakistan                 13                25
Sri Lanka                94                25
Papua New Guinea          -                23
Burkina Faso             43                21
Guinea                   25                21
Afghanistan               5                20
Guinea-Bissau             -                20
Malawi                   55                20
Mozambique               27                20
Togo                      8                20
Angola                   16                19
Yemen                    12                19
Lao Rep.                  7                18
Madagascar               45                17
Mali                     24                17
Rwanda                   25                17
Viet Nam                 70                17
Congo                     -                16
Ethiopia                 10                16
Kenya                    44                16
Myanmar                   -                16
Namibia                  67                16
Nigeria                  31                16
Somalia                   2                16
Central African Rep.     50                15
Congo, Dem. Rep           -                15
Haiti                    20                15
Iraq                     49                15
Nicaragua                59                15
Niger                    16                15
Philippines              28                15
Sudan                    18                15

Less than 20%      
Developing countries with less than 10% low-birthweight
babies, and their rate of institutional births
                          %              % low-
                    institutional        birthweight
                       births            babies

Chile                    98                 5
Paraguay                 55                 5
Turkmenistan             90                 5
Costa Rica               98                 6
Mongolia                 97                 6
U. Arab Emirates         95                 6
Argentina                90                 7
Ghana                    42                 7
Jordan                   78                 7
Kuwait                   97                 7
Saudi Arabia             86                 7
Singapore                99                 7
Botswana                 66                 8
Malaysia                 90                 8
Mexico                   63                 8
Oman                     82                 8
Tunisia                  86                 8
Turkey                   60                 8
Uruguay                  96                 8
Algeria                  76                 9
China                    51                 9
Cuba                     99                 9
Honduras                 45                 9
Iran                     65                 9
Korea, Rep.              99                 9
Morocco                  37                 9
Panama                   84                 9
Venezuela                97                 9
Sources: WHO and updates from UNICEF field offices.

Progress and Disparity

Stunting: A scar and a wound

Stunting (low height for age) in children under age 5 is an
indicator of long-term or chronic malnutrition, reflected by
inadequate growth of the long bones in a child's body.
Stunting is caused by insufficient or poor quality food, poor
feeding patterns, inadequate care of children and women,
frequent infection and poverty. Malnutrition, mostly in mild
or moderate forms, contributes to more than half of all child
deaths and to diminished capacities for those who survive. Low
birthweight may be a result of the mothers stunting (because
of her poor nutrition) and is a significant precursor to
childhood stunting.

In 35 countries (44% of the 80 countries that have data), at
least one in every three children under 5 is stunted. In 10 of
those countries, half or more of the children are stunted.

Stunting weakens immunity, im-pairs learning capacity and work
performance and affects overall quality of life. For girls, it
presents an additional risk: It is associated not only with
low adult height but also with smaller pelvic size, increasing
the risk of obstructed labour and thereby of maternal

Stunting can be either the scar - reflecting an early period
of growth failure - or the  wound' - an indication of ongoing
deficient growth. Height variations resulting from ethnic
differences do not affect stunting data, as such variations do
not tend to show up until adolescence. 

Children of stunted parents tend to suffer the same fate -
adults who began life stunted but whose diets later improved
still tend to give birth to stunted children.

One third or more
Developing countries where 33% or more of under-5s are stunted

Eritrea                  66
Ethiopia                 64
Bangladesh               63
Bhutan                   56
Mozambique               55
Zambia                   53
India                    52
Guatemala                50
Madagascar               50
Pakistan                 50
Lao Rep.                 48
Malawi                   48
Rwanda                   48
Nepal                    47
Tanzania                 47
Viet Nam                 47
Congo, Dem. Rep.         45
Myanmar                  45
Botswana                 44
Mauritania               44
Burundi                  43
Nigeria                  43
Honduras                 40
Yemen                    39
Cambodia                 38
Uganda                   38
Peru                     37
Sierra Leone             35
Central African Rep.     34
Ecuador                  34
Kenya                    34
Sudan                    34
Togo                     34
Lesotho                  33
Philippines              33

One tenth or more
Developing countries where 10% or less of under-5s are stunted


Chile                     3
Trinidad/Tobago           5
Jamaica                   6
Venezuela                 6
Costa Rica                8
Panama                    9
Mauritius                10

Sources:  DHS, MICS and other nationwide surveys (1987-1996).

Progress and Disparity

Slow starters catching up in salt iodization

Three years ago, 48 developing countries were reported in
The Progress of Nations as having no active salt iodization
programmes. Today, most of them have begun to iodize their
salt or import iodized salt. Progress in 14 of them has been
dramatic, with salt iodization levels crossing the 50% mark.
Topping the chart are Tunisia (98%), Lebanon (92%) and
Zambia (90%). Ten of the countries with no data are either
known to be producing iodized salt, have enacted legislation
to do so or have installed the iodizing equipment.

It was estimated that up until 1990, about 40 million
infants - one third of all babies born each year in the
world - were at some risk of mental impairment due to iodine
deficiency in their mothers' diets. This year, because of
the worldwide increase in the use of iodized salt, 12
million children are expected to be spared that risk. And
the number of babies born cretins (suffering from severe and
irreversible mental and physical damage) is expected to have
dropped by more than half, from around 120,000 in 1990 to
under 55,000 worldwide.

Progress in salt iodization
                           % of salt iodized

Tunisia                           98
Lebanon                           92
Zambia                            90
Indonesia                         85
Iran                              82
Burundi                           80
Jordan                            75
Sierra Leone                      75
Uganda                            69
Paraguay                          64
Mozambique                        62
Viet Nam                          59
Malawi                            58
Iraq                              50
Cuba                              45
Mongolia                          42
Philippines                       40
South Africa                      40
Benin                             35
Chad                              31
Central African Rep.              28
Burkina Faso                      22
Yemen                             21
Mali                              20
Turkey                            18
Myanmar                           14
Congo, Dem. Rep.                  12
Angola                            10
Ghana                             10
Haiti                             10
Senegal                            9
Niger                              7
Korea, Dem.                        5
Togo                               1
Afghanistan                        -
Cambodia*                          -
Congo*                             -
Cote d'Ivoire*                     -
Egypt*                             -
Guinea*                            -
Guinea-Bissau*                     -
Lesotho                            -
Liberia                            -
Malaysia*                          -
Morocco*                           -
Papua New Guinea*                  -
Somalia                            -
Sudan*                             -

*Progress among the 48 developing countries that had no salt
iodization programmes in 1994.   

**Some salt is iodized and efforts to increase availability
of iodized salt are under way.

Sources:  UNICEF field offices, DHS and MICS, 1993-1996.

                              * * * *

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