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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
                      * * * *



Fighting AIDS together

Peter Piot*

The world's children are benefiting from several decades of
unprecedented health progress. Child-killing diseases are
succumbing to vaccination campaigns and low-cost remedies,
reducing death rates and improving the quality of young
lives. But in about 30 developing countries, HIV/AIDS is
threatening and even reversing these strides. Meanwhile, in
the industrialized countries, AIDS is starting to be called
a manageable disease, as costly miracle drugs seemingly pull
its victims back from the brink of death. Now the fight
against AIDS faces new dangers: complacency in the
industrialized countries and divisiveness between them and
the developing nations.

In the early days of my involvement in the global effort
against AIDS, I visited the women's medical unit of the
giant Mama Yemo Hospital in Kinshasa. There, women in their
late teens and early twenties, many of whom had supported
themselves as sex workers, were wasting away from
AIDS-related infections. As I passed bed after bed of young
women resigned to death, I realized that similar scenes were
playing out in clinics all over sub- Saharan Africa. I
wondered how we could ever hope to gain any ground against
AIDS in developing countries with primitive medical tools
and scattershot, underfunded prevention programmes. And I
wondered what the explosion of AIDS cases would do to all
the hard-won gains in child survival and development.

That was 14 years ago, and the world community has since
woken up to the crisis and begun to mount a credible
response. But I still hold onto that mental image from Mama
Yemo Hospital and I still hold many of the same concerns:
Despite expenditures of about $18 billion a year (as of
1993), despite emerging miracle drugs, despite the talk of
AIDS as a manageable disease, not enough has changed in
those countries that are home to 90 per cent of the
epidemic, and there are growing indications of division
between those countries and the wealthier ones where people
with AIDS are far fewer and resources far greater. 

Every day, 1,000 children around the world die from AIDS. In
1996 alone, the disease took the lives of 1.5 million
people. About 90 per cent of the 23 million people currently
infected with HIV live in developing countries. Experts
estimate that 30 million to 40 million people will be
HIV-positive by the year 2000, about the same number as the
entire population of Argentina or Spain. 

In about 30 countries, mostly in sub-Saharan Africa, AIDS is
stall-ing and even reversing the best efforts to improve the
health of children and adults, women and men, the poor and
the rich. And only 8 per cent (approximately $1.5 billion)
of the $18 billion a year is being spent on prevention, care
and research in the developing countries.

Even more ominous is the fact that the majority of newly
in-fected adults are under 25 years old, with all too
obvious implications for the future. Women, mostly in their
childbearing years,  now account for nearly half of new

And the worst may be yet to come. According to some
forecasts, rates of infection will not peak until the year
2010 in 19 of the hardest-hit countries, most of which are
in sub-Saharan Africa. While the deaths attributable to AIDS
represent a small percentage of total deaths, they are
enough to reverse some improvements in life expectancy.
Fifteen sub-Saharan African countries may experience a
decline of up to 11 years of life expectancy by the year
2000 compared to projections of deaths without AIDS. 

Still to face the brunt of the epidemic is Asia, home to
over half the worlds population. Despite the fact that AIDS
has only re-cently begun to take hold in the  region, the
number of new infections each day is already comparable to
the number in sub-Saharan Africa. Unless major advances are
made in preventing and treating the disease, projections are
grim for high-population countries like India, where clinic
data show that HIV is beginning to work its way into the
middle class.

And it is not just those who become infected who suffer.
AIDS is a disease with strong ripple effects, primarily
because it strikes so relentlessly at people in the prime of
life. When a mother becomes debilitated by AIDS-related
illness, often the first thing to happen is that her
childrens care suffers. Those children may miss
vaccinations, eat fewer and less nutritious meals, suffer
more bouts of illness. Then a child (or more than one) is
likely to be pulled out of school to work in the market,
cultivate the family plot or care for the baby. 

When the mother dies, she may follow several other extended
family members to the grave, so the likelihood of an aunt or
uncle being able to take in her newly orphaned children is
slim. In regions that formerly were noted for the
unbreakable links of extended family networks, we now have
the shocking reality of households headed by aged
grand-parents or children12-year-olds responsible for
providing food and shelter for a family of even younger

The AIDS tilt

With this devastation so overwhelmingly affecting the
developing world, the effort to fight AIDS is tilted just as
overwhelmingly in the other direction, to the industrialized
world. The most obvious example of this tilt is the new
combination therapies, widely available in industrialized
countries. The cost of these drugs - up to $15,000 a year
per patient - is inconceivable to most people in the
hard-hit nations. For the lucky few who could afford them,
these therapies can be found only in middle-income countries
like Brazil and Thailand; they are virtually unavailable in

But other examples of the tilt abound. Of the $2.6 billion
spent on HIV prevention efforts worldwide each year, only 14
per cent is spent in developing countries. These countries
account for an even smaller proportion - 6 per cent - of the
$11.6 billion spent for care. Research on development of a
vaccine, especially crucial in the hard-hit countries, gets
less than 5 per cent of the $4.2 billion spent annually on
HIV/AIDS research worldwide, according to most recent

The historical lack of funding for vaccine development is
scandalous and irrational, given what is at stake. However,
there is encouraging news from the AIDS Research Evaluation
Task Force of the US National Institutes of Health (NIH). 

The Task Force, overseen and prodded by distinguished
independent scientists, has called for a revitalization of
the vaccine quest. NIH is now considerably increasing its
vaccine efforts. In addition, a consortium of organizations
has founded the International AIDS Vaccine Initiative to
stimulate vaccine research. In particular, the initiative
will support research targeted at HIV subtypes found in
areas of the world where the disease is spreading most
rapidly. Governments must also develop incentives to
encourage serious investment on the part of drug companies
in reaching this goal. 

Funding aside, the concentration of research in the
industrialized world has other worrying implications. For
instance, re-search on preventing mother-to-child
transmission of HIV and on treating HIV-related conditions
in children has been very limited, undoubtedly because these
are largely problems of the developing world. Developing
countries also need to be supported in building their own
capacity to make AIDS medications available to their
citizens who need them.  It is imperative that the
resources, the knowledge and the effort in fighting AIDS be
spread more evenly around the globe. 

At the same time, more must be done to bring comfort to the
lives of people sick from HIV-related illnesses.
Painkillers, antidiarrhoeals, medicines to treat fungal
infections - even these basic medicines are not affordable
to people in the poorest countries.

Achievements at risk 

Hanging in the balance are achievements made by the world
community over several decades in reducing infant mortality
and improving child health and nutrition. Mortality rates
for those under age 5 have been cut in half over the past 30
years. About 8 of every 10 children worldwide are now
immunized against six major childhood diseases: measles,
polio, diphtheria, pertussis, tetanus and tuberculosis.
Polio is on the verge of eradication, and measles and
neonatal tetanus are on the same path. Deaths of children
from diarrhoea - which, along with pneumonia, is the number
one killer of children in poor countries - are also in
retreat because of cost-effective treatments like oral
rehydration therapy (ORT). Since 1985, 2.5 million young
lives have been saved each year through low-cost health

Numbers are faceless, though, and I am fortunate to have
spent enough time in developing countries to have seen the
faces behind the numbers. In 20 years of working in these
countries, I have watched the achievements evolve and met
the people whose lives have been changed as a result. Today
when I travel to Latin America, I see old people crippled by
polio, but not children, because polio has been eliminated
from the western hemisphere. When I travel to countries like
Bangladesh and Kenya, I see packets of oral rehydration
salts for sale in corner kiosks, and I know that many fewer
children are dying from diarrhoea. In Africa, in Asia, in
many places that I travel, I see volunteers going door to
door to make sure that every child turns up for the next
vaccination day, or to support new mothers in breastfeeding,
or to explain how to use ORT.

These achievements are real, and the groundwork is in place
for them to continue. But whenever we start to celebrate
them, they are quickly overshadowed by the bad news about
AIDS. The explanation for its relentless sweep through
communities and countries is rooted in its fundamental
nature. AIDS has succeeded so far in defeating efforts to
stop it because it is not just another disease. Rather, it
is fundamentally a development challenge, intermingling
issues of poverty, inequality, culture and sexuality in
complex ways. 

Worldwide, HIV infection most often results from
heterosexual intercourse. Beyond that biological reality,
some people are especially vulnerable to HIV infection
because of their social, cultural or economic situation. One
such cause of vulnerability is the social inequality between
women and men. Women, especially young women, have little
power to dictate the terms of sexual relationships and are
therefore much more vulnerable to infection. The sugar daddy
phenomenon is not new, but in the age of AIDS, older men are
pursuing ever younger women and girls in the belief that
they are less likely to be infected. Thus, a key to stopping
the epidemic is action that enhances the ability of women
and young people to control their lives, including their
sexual relationships.

Dangers of division

As real strides are made in the industrialized countries,
people are beginning to talk about AIDS as a manageable
disease. A magazine article in the US last December even
wondered if we are in the twilight of AIDS. This sort of
talk brings the potential of dangerous complacency and of
even greater division between the have and the have-not

That is a profound mistake on two counts. On an ethical
plane, it is immoral to describe as manageable a disease
that is only manageable for a fraction of the wealthiest 10
per cent of its victims. On a practical plane, it would be
foolhardy for one simple reason: Like all infectious
diseases, AIDS will not be defeated anywhere until it is
defeated everywhere - miracle drugs or no. 

This is why it is so important that we avoid the temptation
to view AIDS as two different diseases, one that is
manageable in the wealthier countries and one that is a
death sentence in the poorer countries. We are all in this
boat together, and if we slip into an us vs. them view of
the world, we are sunk.

As former Zambian President Kenneth Kaunda said in a recent
speech invoking the memory of his son, dead from AIDS in
1986, Every one of us ignores AIDS in the house of their
neighbour at their own peril. If we can stick together, if
governments and NGOs and committed individuals in every
community in every country are willing to learn from the
painfully earned wisdom of their neighbours around the
world, we can slow down and even reverse this epidemic. We
do not have to watch these grim numbers continue their march
across the world map. 

To stop that march, we need accessible, affordable ways to
prevent transmission between sexual partners and from
mothers to children. This includes access to affordable and
high-quality condoms, and increasingly to the recently
developed condom for women. In 1994, US trials of a new
drug, zidovudine (ZDV), to help HIV-positive mothers give
birth to healthy babies had striking results: a two-thirds
decrease in HIV transmission. But it is beyond the reach of
poor women. UNAIDS, the US Centers for Disease Control and
Prevention, and other organizations are now collaborating
with researchers in Africa and Asia to find economical ways
to make ZDV available where it is most needed. Other
low-cost drugs to prevent mother-to-baby transmission during
pregnancy and childbirth are under development and look

One of the problems facing families and health workers in
developing countries is the potential for HIV infection
through breastfeeding. While the factors determining
transmission of the virus from mother to baby are not yet
fully understood, studies suggest that breastfeeding confers
a 1-in-7 risk of infecting the baby with HIV.

An HIV-positive mother now faces a quandary. If she is
affluent, she probably lives in a setting that makes the use
of breastmilk substitutes a reasonable option. In all
likelihood, she has easy access to safe water (or fuel to
boil the water) for mixing the formula and cleaning the cups
or bottles. She can afford as much formula as her baby
needs. Attentive health services are available to treat the
additional infant illnesses that may accompany use of
breastmilk substitutes. Although in a perfect world
breastfeeding is always the best option, for a well-to-do
woman infected with HIV, using formula might be a good

But mothers at the bottom of the economic ladder face a
cruel dilemma: They can either breastfeed, with the risk of
passing along HIV, or they can use breastmilk substitutes,
with the risk of exposing their babies to potentially lethal
diseases and to malnutrition from formula that is

If we know that some babies are becoming infected through
breast-milk, we have a moral obligation to do everything we
can to prevent those infections. First, we must make sure
that every woman has access to affordable, confidential HIV
testing. If she takes the test and it turns out positive,
she must be supported in making the agonizing infant-feeding
decision. She needs to be informed in a respectful way about
the relative risks so that she can make a choice based on
accurate facts. 

Where safe water is accessible close by, and where
breastmilk substitutes are available at reasonable cost, an
HIV-infected mother might choose to feed formula to her
child. However, she herself is powerless to ensure a
reliable water supply or quality health services, nor can
she influence the price of formula. These are matters of
public health, and that is the responsibility of

When leaders lead

A few heroic leaders understand AIDS for the profound
development challenge it is, and they have approached it
with an unprecedented call to action. When that becomes part
of the national consciousness, the worst effects of the
epidemic can be avoided. 

Ugandan President Yoweri Museveni, for example, rarely
delivers a speech in which he does not mention AIDS, and the
trickling down of that rhetoric is at least partly
responsible for the levelling off of infection rates in
urban areas of Uganda. Some surveys in antenatal clinics
there have found that between 1990-1993 and 1994-1995, HIV
prevalence among women aged 15-24 de-clined by 35 per cent.

In South Africa, President Nelson Mandela has called for a
national struggle to vanquish AIDS on a scale similar to
that mobilized to bring down apartheid. Zimbabwe responded
to high HIV prevalence rates with a mandatory weekly lesson
in life skills for all students aged 9 to 19. The course,
begun in 1993, addresses HIV/AIDS in the context of coping
with emotions and expectations, gender roles and plans for
the future, and students role-play to develop strategies for
responding to peer pressure.

Similar bright spots of leadership are occurring in Asia.
Only a few years ago, Thailand was viewed by complacent
neighbours as the only country in the region likely to have
a significant problem with AIDS. The virus had gained a
foothold in 1988, and the availability of commercial sex in
the country of 59 million people allowed it to flourish. As
a result, about 45,000 Thais died from HIV infection in

But Anand Panyarachun, who was Prime Minister in 1991 and
1992, instituted a far-reaching AIDS education programme
that has put Thailand in much better shape than some of its
neighbours.  Mr. Anand required every government minister
toinclude a budget line for AIDS. the centrepiece of a
public education programme wa a series of explicit AIDS
prevention message aired on radio stations at least once
every hour. Condoms were widely distributed to brothels. 
Sex businesses that refused to require condoms use were shut
down. Calls for abstinence from casual sex were partnered
with the condom campaign, promoted tirelessly by the Prime
Minister's dynamic AIDS adviser, Mechai Viravaidya.

As a result, thee was an 80 per cent decrease in sexually
transmitted diseases in Thailand from from 1989 to 1994. The
number of new HIV infections in Thailand each year has more
than halved since 1990.  Success stories like these should
be the most powerful argument against complacency. 
These successes demonstrate that if we focus our efforts on
those most vulnerable, if we expand use of the communication
tools that work and commit ourselves to developing a vaccine
and affordable drugs, we can stop this plague. We already
proved we can muster global will and resources with the
campaign that raised vaccination rates worldwide from 40 per
cent to 80 per cent in just five years.
The worst that can happen for our prospects of wiping this
virus from the earth is to allow complacency and
divisiveness between the haves and have-nots to prevent us
from developing responses that work in the countries where
they are most needed. We can defeat HIV/AIDS - if we all
acknowledge our ownership of it.
President Mandela said it best: "As the freedom of each
nation is interdependent with that of others, so too is the
health and well-being of their peoples. Nowhere is this more
true than in the case of AIDS. The challenge of AIDS can be
overcome if we work together as a global community."

                        # # # # #                

*Dr. Peter Piot, Executive Director of the Joint United
Nations Programme on HIV/AIDS (UNAIDS), has been working on
the international fight against HIV/AIDS for 14 years.
Before UNAIDS was formed in 1996, he was responsible for
AIDS research and development activities at WHO.  Formerly,
at the Institute of Tropical Medicine in Antwerp (Belgium),
Dr. Piot established a group devoted to research, training
and technical cooperation on the disease and on reproductive
health. He was among the first to document a number of
important aspects of the epidemic in developing countries
and co-launched Project SIDA in Kinshasa (Democratic
Republic of Congo), the first international HIV/AIDS project
in the developing world. He was also a co-discoverer of the
Ebola virus in 1976.

Gauging AID's terrible toll

How many infants will die of AIDS in the year 2010? Anywhere
between 83,000 and 357,000 in just 19 of the high-risk
countries. The more conservative estimates come from the UN
Population Division, which believes that, with 75,000
infants (under 1 year of age) dying of AIDS in 1995, the
pandemic essentially levelled off. But the estimates by the
United States Bureau of the Census are more pessimistic:
AIDS took 105,000 infant lives in 1995 in the 19 countries,
and the toll will surge to more than 3 times that number in
2010 - more than 10 times the number of infant deaths from
all causes in Europe (except Eastern Europe).

The main reason for the difference between the two estimates
is their assumptions as to the timing of the peak of the
epidemic in these countries: The Census Bureau believes that
the peak will come in 2010, while the UN believes it peaked
in 1995. In the 19 countries, the Census Bureau attributes
26% of infant mortality to AIDS in 2010, whereas the UN
estimate is 8%. 

As to the impact on individual countries, the Census Bureau
projects that in Kenya, AIDS will claim 51,000 infants in
2010, 41% of all infant deaths in the country. The
comparable UN estimate is 12% or 12,200 infants. In
Zimbabwe, according to the Census Bureaus calculations,
36,300 infants will die of AIDS in 2010, 58% of the total;
the UN estimate is 11,500 deaths or 27% of all babies dying
in the country. But Botswana is projected to be the biggest
casualty of the scourge in 2010 - 61% or 4,500 of 7,500
total infant deaths (according to the Census Bureau) and 35%
or 1,600 of 4,500 infant deaths (according to UN figures).

The projections cover 19 of the 32 hardest hit countries
where HIV/AIDS now rages. But the epidemic is only beginning
to grow in Asia, for example, and new countries could appear
on this chart if prevention and control efforts do not take

Worldwide, the percentage of infant deaths attributable to
HIV/AIDS is still small. That is because at this time AIDS
is not a  significant cause of infant or child death in the
countries with the biggest percentage of the worlds
children, especially China and India. 

It is important to remember that the impact of HIV/AIDS on
children is not only measured in statistics on their health
but also in the health of their parents and communities. A
young child whose parents are sick or dead is at heightened
risk of death from preventable diseases and malnutrition,
while older children (girls especially) must often leave
school to care for sick parents, mind younger siblings or go
to work.  In all of these ways, the effect of HIV/AIDS on
development is potentially enormous - and as yet unmeasured.

Per cent of infant deaths due to AIDS
Projections for the year 2010

            US Bureau of the           UN Population
                Census                   Division

               % infant mortality due to AIDS

Botswana          61                       35
Zimbabwe          58                       27
Kenya             41                       12
Zambia            40                       17
Rwanda            31                        6
Uganda            31                       10
Malawi            30                        9
Tanzania          29                        6
Burkina Faso      27                        6
Cote d'Ivoire     26                        8
Cen. African Rep. 23                        6
Lesotho           20                        5
Burundi           18                        3
Cameroon          18                        5
Congo             16                       11
Brazil            13                        0
Congo, Dem. Rep.  10                        3
Haiti              7                        7
Thailand           5                        7            

Sources: US Bureau of the Census, The Demographic Impacts of
HIV/AIDS: Perspectives from the World Population Profile,
1996; UN Population Division, World Population Prospects:
The 1996 Revision, 1997.

Health League Table
Child Death Rates

The proportion of children who reach their fifth birthday is one
of the most fundamental indicators of a country's concern for its
people.  Child survival statistics are a poignant indicator of
the priority given to the services that help a child to flourish:
adequate supplies of nutritious food, the availability of high-quality
health care and easy access to safe water and sanitation
facilities, as well as the family's overall economic condition
and the health and status of women in the community.

Re-slicing the cause-of-death pie

*ARI               19%
Dairrhoea          19%
Perinatal causes   18%
**NCDs             10%
Measles             7%
Injuries            6%
Malaria             5%
Other              16%

Determining the cause of death for children under 5 has always
been a more difficult task then estimating the number of child
deaths.  Better estimates of the cause of child death have
resulted from a new global study by WHO, the World Bank and
Harvard University, reflected in the table above.

The table revises earlier estimates of the proportion of deaths
attributable to each cause.  It also provides information on two
categories - injuries and non-communicable diseases - not
previously included in cause-of-death estimates.

Although the new table attributes a smaller percentage of deaths
to diarrhoea and acute respiratory infections, it confirms them a
the leading causes of child death.  Malnutrition alone accounts
for just 3% of the under-5 deaths, but it plays a contributing
role in more than half of all child deaths in developing

*Acute respiratory infections.
**Non-communicable diseases.

Sources: Adopted from Global Burden of Disease, WHO, World Bank
and Harvard University, 1996.

What the table ranks

Percentage reduction in under-5 mortality rates from 1980 to
1995.  The 1995 rate per 1,000 births is in parentheses.

1  Gambia (110                   56
2  Botswana (52)                 45
2  Mauritius (23)                45
4  Zimbabwe (74)                 41
5  Senegal (130)                 40
6  Cameroon (106)                39
7  Rwanda (139)                  37
8  Burkina Faso (164)            33
9  Namibia (78)                  32
10 Togo (128)                    27
11 Chad (152)                    26
11 South Africa (67)             26
13 Eritrea (195)                 25
16 Gabon (148)                   24
16 Madagascar (164)              24
16 Malawi (219)                  24
19 Guinea-Bissau (227)           22
19 Mauritania (195)              22
21 Guinea (219)                  21
21 Mozambique (220)              21
23 Kenya (90)                    20
24 Benin (142)                   19
24 Uganda (145)                  19
26 Lesotho (140)                 17
27 Ghana (130)                   16
Regional average (174)           14
28 Congo (108)                   14
28 Somalia (211)                 14
30 Cote d'Ivoire (150)           12
31 Tanzania (160)                11
32 Burundi (176)                  9
33 Central African Rep. (165)     8
33 Liberia (216)                  8
35 Sierra Leone (284)             6
36 Nigeria 9191)                  3
37 Congo, Dem. Rep. (207)         1
38 Niger (320)                    0
39 Angola (292)                 -12
40 Zambia (203)                 -27


1  Oman (25)                     74
2  Egypt (51)                    72
3  Algeria (40)                  71
4  U. Arab Emirates (19)         70
5  Iran (40)                     68
6  Turkey (50)                   65
7  Tunisia (37)                  64
8  Jordan (25)                   62
8  Saudi Arabia (34)             62
10  Kuwait (14)                  60
Regional average (57)            59
11  Israel (9)                   53
12  Morocco (75)                 51
12  Syria (36)                   51
14  Yemen (110)                  48
15  Libya (63)                   47
16  Sudan (115)                  43
17  Iraq (71)                    14
18  Lebanon (40)                  0

1  Kyrgyzstan (54)               40
2  Tajikistan (79)               37
2  Uzbekistan (62)               37
4  Georgia (26)                  35
5  Kazakstan (47)                34
6  Turkmenistan (85)             33
7  Azerbaijan (50)               15
Regional average (132)           12
8  Armenia (31)                   9
9  Afghanistan (257)              8

1  Malaysia (13)                 69
2  Sri Lanka (19)                63
3  Viet Nam (45)                 57
4  Singapore (6)                 54
5  Korea, Rep. (9)               50
6  Thailand (32)                 48
7  Cambodia (174)                47
8  Bangladesh (115)              45
8  Japan (6)                     45
10 New Zealand (9)               44
11  Indonesia (75)               41
12  Australia (8)                38
13  Nepal (114)                  37
14  India (115)                  35
15  Mongolia (74)                34
Regional average (85)            31
16  Korea, Dem. (30)             30
17  Lao Rep. (134)               29
18  China (47)                   28
19  Bhutan (189)                 24
19  Philippines (53)             24
21  Pakistan (137)                9
22  Papua New Guinea (95)         0
23  Myanmar (150)                -3

1  El Salvador (40)              67
1  Jamaica (13)                  67
3  Mexico (32)                   63
4  Cuba (10)                     62
4  Honduras (38)                 62
6  Ecuador (40)                  60
7  Nicaragua (60)                58
7  Peru (55)                     58
9  Chile (15)                    57
9  Guatemala (60)                57
9  Trinidad/Tobago (18)          55
12  Dominican Rep. (44)          53
Regional average (34)            51
13  Uruguay (21)                 50
14  Colombia (32)                45
14  Costa Rica (16)              45
16  Paraguay (34)                44
17  Venezuela (24)               43
18  Brazil (53)                  42
19  Bolivia (105)                38
19  Canada (8)                   38
21  Haiti (124)                  36
22  Panama (20)                  35
23  Argentina (27)               34
24  United States (10)           33

1  Portugal (11)                 65  
2  Austria (7)                   59  
3  Greece (10)                   57  
4  Germany (7)                   56  
4  Slovenia (8)                  56  
6  Bosnia/Herzegovina (17)       55  
6  TFYR Macedonia (31)           55  
8  Italy (8)                     53  
9  Czech Rep. (10)               50  
9  Ireland (7)                   50  
9  United Kingdom (7)            50  
12 Yugoslavia, Fed. Rep. (23)    48  
13 Hungary (14)                  46  
14 Finland (5)                   44  
14 Spain (9)                     44  
14 Sweden (5)                    44  
Regional average (16)            41  
17 Croatia (14)                  39  
18 Belarus (20)                  38  
19 Switzerland (7)               36  
20 Slovakia (15)                 35  
21 Belgium (10)                  33  
21 Poland (16)                   33  
23 Lithuania (19)                32  
24 France (9)                    31  
24 Moldova, Rep. of (34)         31  
26 Albania (40)                  30  
26 Denmark (7)                   30  
26 Russian Fed. (30)             30  
29 Latvia (26)                   28  
30 Estonia (22)                  27  
30 Netherlands (8)               27  
30 Norway (8)                    27  
33 Bulgaria (19)                 24  
34 Ukraine (24)                  23  
35 Romania (29)                  19  
Source: UNICEF

                   15 years of progress

                          1980         1995

Sub-Saharan Africa        202           174
Middle East &
 North Africa             139            57
Central Asia              150           132                      
East/South Asia
 & Pacific                123            85
Americas                   69            34          
Europe                     27            16

Under-5 mortality rate (deaths per 1,000 live births)

Source: UNICEF

Progress and Disparity

Pneumonia: Little progress on a big killer

Acute respiratory infections (ARI), mainly pneumonia, kill
more than 2 million children each year. Yet many countries are
only beginning to take steps to reduce the devastating but
largely preventable toll. Many ARI deaths could be averted if
families knew pneumonia's danger signs, if health workers were
trained to diagnose and treat pneumonia, and if clinics
stocked life-saving antibiotics. Since 1992, however, only 16
countries have undertaken surveys of clinics to determine
health workers' training and the availability of basic
antibiotics. And only 23 countries have completed household
surveys to gauge families' awareness of danger signs. 

In 10 of the countries that surveyed clinics, fewer than half
of health workers are trained in pneumonia case management. In
several countries, such as Colombia, the Dominican Republic,
Indonesia, Malaysia, Thailand and Zimbabwe, a high percentage
of clinics stocked antibiotics, but a much lower percentage of
health workers were trained to treat pneumonia. Pakistan and
Papua New Guinea had low rates for both antibiotics and
training. Among countries with household surveys, only in
Egypt do more than half of caretakers know when to seek

But there is good news from the world's two most populous
countries: China has trained 88% of health workers in standard
case management of ARI, and India is a close second at 87%.
Nearly all clinics surveyed in both countries stock necessary

At the beginning of this decade, few countries had programmes
to reduce mortality from pneumonia. Of 88 countries where
pneumonia is thought to be common, 59 have now started control
programmes, and household surveys are being carried out in 60

First steps in taming a killer
Countries with clinic surveys of ARI* management

                  % health workers      % clinics
                   trained in case      with basic
                      management        antibiotics

China                   88                  99
India                   87                  94
Philippines             83                  52
Bangladesh              66                  94
Viet Nam                65                   -
Sudan                   64                  68
Morocco                 47                  79
Paraguay                46                  60
Thailand                44                  87
Colombia                36                  67
Papua New Guinea        33                  27
Pakistan                29                  38
Dominican Rep.          26                  82
Zimbabwe                25                  97
Malaysia                23                 100               
Indonesia               18                  63

Countries with household surveys of ARI home management

                          % caretakers knowing
                            when to seek care

Egypt                              57
Sudan                              48
Swaziland                          48
Philippines                        44
Uganda                             41
Viet Nam                           40
Mongolia                           36
Cote d'Ivoire                      35
India                              35
Somalia                            35
Sri Lanka                          35
Tanzania                           33
Nigeria                            32
Myanmar                            26
Turkmenistan                       26
Kyrgyzstan                         25
Ghana                              24
Congo, Dem. Rep.                   22
Pakistan                           20
Ethiopia                           19
Lao Rep.                           18
Papua New Guinea                   15
Yemen                               7

*Acute respiratory infections

Sources: WHO, Division of Diarrhoeal and Acute Respiratory
Disease Control, 1994-1995 Report; UNICEF, unpublished data,

Progress and Disparity

52 countries falling short on immunization goal for DPT

Reaching the year 2000 goal of 90% immunization levels is a major
challenge for many countries. At least 52 countries with
populations of more than 1 million are unlikely to meet the goal
of immunizing all children under the age of 1 against DPT
(diphtheria, pertussis and tetanus). From 1980 to 1990,
developing countries accomplished extraordinary gains for child
health by raising immunization rates for DPT, as well as measles,
polio and tuberculosis, from about 30% to an average of 80%.

Sub-Saharan Africa faces the greatest difficulties, with 31
countries projected to fall short of the DPT immunization goal.
Angola, Central African Republic and Chad could have DPT
immunization rates of less than 20% in the year 2000 unless they
are able to reverse current trends. Countries in other regions
with low projected rates include Haiti, Nepal, Pakistan, Papua
New Guinea and Yemen. Immunization data are a basic child health
indicator, but seven industrialized countries have inadequate
data: Australia, Austria, France, Ireland, Japan, New Zealand and
Switzerland. Most of the other industrialized countries are
projected to attain DPT (or DT only) immunization levels of at
least 85%. 

Despite concern that commitment to immunization might waver after
the 1990 achievement, 90 countries are on track towards the year
2000 goal, based on their 1990 to 1995 performance. Current
levels of DPT immunization save the lives of more than 1 million
children each year.

Immunizing for the year 2000
Countries unlikely to meet the goal of
90% coverage of DPT by the year 2000

Projected immunization rate by the year 2000

Sub-Saharan Africa

Zimbabwe        82
South Africa    80
Kenya           79
Botswana        71
Zambia          66
Malawi          65
Liberia         64
Senegal         62
Ethiopia        59
Cote d'Ivoire   56
Ghana           53
Togo            50
Mali            48
Burundi         46
Eritrea         46
Mozambique      46
Lesotho         44
Gabon           40
Rwanda          39
Uganda          39
Cameroon        38
Somalia         38
Congo           32
Nigeria         31
Niger           28
Burkina Faso    27
Sierra Leone    22
Congo, D. Rep.  21
Angola          19
C. African Rep. 18
Chad            14

Middle East and North Africa

Sudan           81
Yemen           15

Central Asia

Turkmenistan    81
Kyrgyzstan      68
Afghanistan     67
Georgia         49

East/South Asia and Pacific

Philippines     81
Myanmar         75
Bangladesh      62
Nepal           47
PNG*            36
Pakistan        13


Uruguay         84
Brazil          81
Paraguay        80
Costa Rica      76
Venezuela       72
Haiti           28


TFYR Macedonia  82
 Herzegovina    78
Latvia          50

*Papua New Guinea
Sources: WHO and UNICEF, unpublished data for 1990 and 1995.

Progress and Disparity

Neonatal deaths: 5 million each year

Of the annual 8 million infant deaths worldwide occurring during
the first year of life, 5 million are neonatal deaths - those
taking place during a baby's first four weeks. A total of 98% of
all neonatal deaths are in developing countries.

As a country's infant mortality rate falls, the proportion of
neonatal deaths tends to rise. This is true both in developing
countries and in the industrialized countries.

A baby is at greater risk during delivery and the first month of
life than at any other point during childhood. And 85% of all
neonatal deaths are due to birth asphyxia and trauma, tetanus,
premature birth and infections. But there is an erroneous belief
that these most common causes of death in developing countries
are not responsive to public health measures. 

Cost-effective interventions can, in fact, significantly reduce
neonatal (as well as maternal) mortality. These include
vaccinating women of child-bearing age against tetanus; promoting
good maternal nutrition; ensuring prenatal care and deliveries by
skilled birth attendants; and upgrading health facilities with
equipment, drugs and staff training needed to treat obstetric and
neonatal emergencies. Newborns need immediate breastfeeding,
warmth, cleanliness, hygienic care and resuscitation when
necessary. Some will also need special attention for the early
detection and treatment of illnesses. 

In the industrialized countries, where infant deaths are much
more rare, neonatal deaths constitute an even higher proportion
of the infant mortality rate. Most neonatal deaths in these
countries result from congenital abnormalities and premature

Progress and Disparity

Malaria's death toll: A child every 30 seconds

Alone or in conjunction with other illnesses, malaria kills over
1 million children under age 5 every year a child every 30
seconds. Children experience over half of all malaria episodes.

Four species of the malaria parasite, transmitted by the
Anopheles mosquito, affect humans, but the most dangerous
species, causing nearly all malaria-related deaths, is Plasmodium
falciparum, which predominates in sub-Saharan Africa and parts of
South-East Asia, Oceania and South America. Over 40% of the
worlds population lives in malaria-endemic areas, but 90% of the
estimated annual 300 million to 500 million malaria cases afflict
people in sub-Saharan Africa.

Prevention efforts against malaria have had mixed results.
Although water-drainage and insecticide-spray programmes have
been effective in some parts of the world, they have not proven
to be practical or sustainable in the more severely affected
regions. Additionally, no vaccine against malaria is likely to be
available for routine use in the near future. However, another
preventive measure, insecticide-impregnated bednets or curtains,
has proven to reduce deaths among children in Africa. Initiatives
are under way to promote the widespread use of these materials,
though the initial cost of buying them and the added expense of
subsequent treatments with insecticide are beyond the reach of
many poor families.

As prevention is so difficult, the ability to provide effective
treatment for malaria is of great importance. But treatment has
also been made more difficult because nearly everywhere that
falciparum is prevalent, it is at least partially resistant to
chloroquine, the cheapest and most widely available medication.
The problem of falciparum drug resistance is most acute and
severe  in parts of South-East Asia and Brazil where malaria may
also be resistant to the readily available second-line

The challenge of drug resistance demands that health workers be
trained to recognize and provide proper treatment for the problem
and that health systems have appropriate  drugs available.

Where P.falciparum is chloroquine-resistant

Sub-Saharan Africa

Burkina Faso
C. African Rep.
congo, Dem. Rep.
Cote d'Ivoire
Sierra Leone
South Africa

Middle East and North Africa


Central Asia


East/South Asia and Pacific

Lao Rep.
Papua New Guinea
Sri Lanka
Viet Nam



*P.falciparum has widespread resistance to more than one drug.

Source: WHO, International Travel and Health, Vaccination
Requirements and Health Advice, 1997.

                              * * * *

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