Working Group on Women and Child Health, F Dabis,
chair of working groupa, J Orne-Gliemann,
scientific secretary of working groupa, F Perez,
member of working groupa, V Leroy,
member of working groupa, M L Newell,
co-chair of working groupb, A Coutsoudis,
member of working groupc, H Coovadia,
member of working groupc.
a Institut de Santé Publique, d'Epidémiologie et de Développement
(ISPED), Case 11, Université Victor Segalen-Bordeaux 2, 33076 Bordeaux Cedex,
France, b Centre for Paediatric Epidemiology and Biostatistics,
Institute of Child Health, London WC1N 3JH, c Department of
Paediatrics and Child Health, University of Natal, Durban, South Africa
Child health has improved greatly in the past decade, thanks to research that
has quantified health problems and identifiedstrategies for
improving child health. The Working Group on Womenand Child Health
reviews the major advances in this field in developingcountries
since 1990 and argues that research is fundamental tofurther
improvements in child health
Child mortality (before age 5 years) has shown a relative decrease of 15%
since 1990 but remains above 100 per 1000 live birthsin more than
40 countries.1 The risk of death can be reducedthrough evidence based interventions such as immunisation and
oral rehydration treatment. Research has helped to quantify child
health problems, identified strategies to improve health, andshown
the effectiveness of interventions. In preparation for the
forthcoming United Nations special session on children, we reviewthe
major advances in child health in developing countries since1990 and
illustrate the role of research in this progress.
Summary points
Child health has improved markedly over the past 10 years
In many developing countries, mortality among children under 5 remains
above 100 deaths per 1000 live births; most of these deaths are
preventable
Reduction of childhood morbidity and mortality remains a public health
priority worldwide
Investing in survival of children is an essential element of national
development
Research is fundamental to further improvements in child health
Without continued and increased research investment, further advances
to improve the health of the world's children are put at risk
Methods
We reviewed the literature published between January 1990 and June 2001 to
document progress of and challenges in child healthresearch since
the previous UN session for children in 1990. TheMedline search
strategy was based on the combination (Booleanoperator AND) of
"child" and "developing countries" and the followingkeywords:
breastfeeding, diarrhoeal diseases, health system, HIVinfection,
immunisation, injuries, malaria, measles, mental health,mortality,
opportunistic diseases, oral health, perinatal health,respiratory
infections, sanitation, and welfare. The search identified
4701 references, of which we selected 488 on title and 137 on
content. We identified unpublished documents and reports by major
child health institutions through an electronic mail survey toover
90 informants in national and international public, private,and
non-profit organisations.
Leading causes of disability adjusted
life years (DALYs)* worldwide in 19902
The magnitude of child morbidity and
mortality
Five of the 10 most important conditions contributing to the global burden of
disease are childhood diseases (table 1). Respiratoryinfections and diarrhoeal diseases are the most important causesof mortality in children under 5, with about eight million deathsglobally each year.2 Most deaths are
preventable by targetingfactors such as fertility behaviour,
nutritional status of children,and breastfeeding patterns (fig
1).3
Research to improve child survival
Child health research aims to quantify childhood mortality and morbidity,
improve understanding of causes, and identify appropriate
interventions (table 2). The following three examples documentthe value of child health research, leading to successful interventions,translation of research findings into public health practice,
and subsequent improvement in survival ofchildren.
Vitamin A deficiency
Vitamin A deficiency is a major cause of childhoodblindness and a
contributor to mortality from measles and diarrhoeain Asia and
Africa. In the early 1990s, results from observationalstudies showed
an increased mortality among children with clinicalxerophthalmia.
Randomised trials subsequently showed that improvingthe vitamin A
status of deficient children significantly reducedmortality,10-12
although not always.13 A South African studyfound that vitamin A supplementation in children with moderate
or severe measles halved mortality.14 Large dose
vitamin A treatmentthus became part of the routine management of
measles, to reducethe incidence of both blindness and fatality.
Vitamin A supplementationmay also improve outcome in HIV infected
children with diarrhoea.15
International agencies have worked with governments from affected areas to
train healthcare workers in distributing vitaminA and setting up
food fortification programmes, linking vitaminA distribution to
immunisation programmes and other child survivalprogrammes (box
1).16 Further research should
focus on waysto monitor and evaluate such programmes and extend
their coverageto children who do not routinely access health
services.
Types of research in the area of
child health and nutrition
Box 1: Research on
vitamin A deficiencylessons
learnt
Research findings and development of indicators to assess
vitamin A status by biologists, nutritionists, clinicians, and
epidemiologists with international agencies have encouraged the
development of programmes to prevent vitamin A deficiency at
national levels
Research into social marketing, education, and communication
strategies to encourage changes in dietary practices and delivery
of health services has contributed substantially to improving the
coverage of effective programmes
Mother to child transmission of HIV
Results from epidemiological studies in thelate 1980s and early
1990s revealed that, worldwide, at least30% of infants born to HIV
infected mothers acquired HIV infection.In some developing countries
the prevalence of HIV infection inpregnant women now approaches
30-40%, and mother to child transmissionof HIV contributes
substantially to child mortality.17 Suchtransmission can occur in utero, intrapartum, and postpartum viabreast milk.18
Reducing maternal HIV viral load through antiretroviral treatment
administered prophylactically before and during delivery
significantly reduces the risk of transmission.19-22
Further reductionin the risk of mother to child transmission in
developed countriescan be achieved through delivery by elective
caesarean section,combination antiretroviral treatment, and
avoidance of breastfeeding. In countries where randomised trials
have shown simpleand shorter antiretroviral prophylaxis
interventions to be effective,results from observational studies are
now showing the effectivenessof such interventions outside trial
settings. 2324
Postnataltransmission through breast feeding remains an important
problem,however, and further research is ongoing to improve the
safetyof breast feeding in settings with high prevalence of HIV andwhere refraining from breast feeding is not anoption.
Thus, by 2000, governments and organisations such as the World Health
Organization, Unicef, and UNAIDS could make informedpolicy decisions
to prevent mother to child transmission of HIV.25Currently, the focus is on the wider implementation of simplifiedinterventions along with guidelines on breast feeding. Research
should now aim to identify behavioural, social, cultural, and
economic factors that may limit access to and use of these effective
interventions (box 2).26
Box 2: Research on
preventing mother to child transmission of HIVlessons
learnt
Large, sustained, and coordinated research effort with clear
goals can yield high impact results
Science has informed evidence based strategies to
substantially reduce mother to child transmission, but these
strategies are far from being universally applied
Research now needs to identify ways to reach the women and
children who are at greatest risk
Malaria prevention and bed nets
Malaria in children is estimated to causeone million child deaths
each year in sub-Saharan Africa.2
Clarification of the role of the life cycles of parasites and
mosquitos led to the hypothesis that the number of infective bites
could be reduced by using protective bed nets. Indeed, the useof bed
nets treated with non-toxic, synthetic pyrethroid has beenshown to
result in significant reduction of febrile episodes inchildren27
and all-cause mortality among children aged 1-4 years,28although the methods of insecticide application have caused concern.29Large scale effectiveness studies in the Gambia and Kenya show
the impact of this form of malaria control in national programmeson
child mortality23 and paediatric hospital
admissions.30The evidence base for the
use of insecticide treated bed netshas recently been greatly
enhanced by economic evaluations conductedalongside these trials.31
The transition of research results into a sustainable public health
intervention has been hampered by cost, compliance, andpublic
acceptance (box 3). Research is now needed to clarify thevalue of social marketing, the effect of affordable price scales,and requirements for behavioural change. The recently published
results from a Tanzanian study taking these factors into account
showed that the large scale use of bed nets remained effectivefor at
least three years, improving child survival by 27%.32
Box 3: Research on
use of bed nets for preventing malarialessons
learnt
Research has led to the development of a low cost intervention
against malaria
The low number of children sleeping under insecticide treated
bed nets at night calls for operational research at a family level
to improve access and proper use
Sustained availability of this intervention requires effective
infrastructures and mechanisms, able to empower communities to
tackle childhood malaria
Research challenges for the next decade
Evidence from child health research over the past 10 years has provided
guidance to decision makers. Priority must be givento funding
research that will optimise health benefits in themost appropriate
and effective way (table 3).33
Selected research challenges for the
next decade to further improve child health in developing countries
To maximise efficiency and responsiveness of research into child health and
nutrition, setting of research priorities shouldbe based on
evidence, consider local ownership and partnership,respect ethical
issues, and address the interactions between childhealth and other
sectors. 23435 The multiplicity of childhealth
determinants calls for a multisectoral partnershipa
combinationof socioeconomic policies and health interventions.
Further researchto inform such policy packages is
essential.
The burden of childhood morbidity and mortality could be further reduced
through the reduction of gaps in research resourcesand capacity.
Although there are limited accurate estimates ofglobal spending and
the amount allocated for research on the maindiseases, an imbalance
exists between the burden of disease andinvestment in research and
development for the world's two biggestkiller diseases (fig
2). Although pneumonia and diarrhoeal diseases
represent 11% of the global burden of disease, and a much higher
percentage in children (38%), only an estimated 0.2% of the total
amount spent on research and development is allocated to these
conditions.38
Fig 2. Main causes of death in
children under 5 years of age in developing countries, 1995 (adapted
from Murray and Lopez36 and Pelletier et
al37)
Research evaluating the effectiveness and safety of population based
intervention packages would contribute to appropriateuse of funds
and prioritise effective interventions in child healthand nutrition.39
To maximise support for initiatives in childresearch and the impact
of available research results, each country,no matter how poor,
should adopt essential national health researchstrategies
emphasising priorities and national ownership of researchfindings,
equity in health care, and translation of research intopolicy and
action.35
Strengthening links between non-governmental organisations, health workers,
religious leaders, women's groups, and othersand integrating the
health system and other sectors into a dynamicnetwork are important
for the introduction of programmes basedon research findings.40
Furthermore, many results of child healthresearch from one setting
will be applicable to anotherfor
example,vaccines to protect individual children and communities;
diseaseeradication programmes (poliomyelitis); and effective controlof communicable diseases such as tuberculosis, measles, malaria,and AIDS. Such transfer of knowledge has been successful in the
1990s but needs to be further encouraged andstrengthened.
Conclusion
Research has resulted in substantial progress in child health over the past
10 years, but many problems remain to be tackled.Further progress
requires that research continues to deal withthe needs of children
affected by preventable conditions in thedeveloping world.
Strengthening national research capacities torespond to local health
needs is fundamental for the implementationand sustainability of
research findings at a population level.A dynamic interaction
between researchers, policy makers, advocacygroups, and funding
institutions, within developing and developednations, is essential
to ensure that priorities in child researchare based on sound
evidence and remain at the top of the internationaldevelopmentagenda.
Acknowledgments
We thank E Mouillet (ISPED) for assistance with the literature review.
Unpublished material and reports were made availableby A de
Francisco (Global Forum for Health Research, Geneva) andO Fontaine
(WHO, Geneva). The Global Forum for Health Researchcommissioned us
to prepare a report on the status of child healthand nutrition
research (Child health research: a foundation forimproving child
health. Geneva: WHO, 2002. (WHO/FCH/CAH/02.3.)),which forms the
basis of this review paper. We also thank theparticipants in the
Global Forum for Health Research Workshopin Geneva, Switzerland,
18-21 April 2001, for their input in reviewingthe background
document used for this paper. Special thanks aredue to the
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OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
"A foolish faith in authority is the worst enemy of truth."
-- Albert Einstein, letter to a friend, 1901
"I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."
-- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820
"What's the point of vaccination if it doesn't protect you from the unvaccinated?"
-- Sandy Gottstein
"Who gets to decide what the greater good is and how many will be sacrificed to it?"
lessons
learnt 
