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Counting the uncountable? Measuring progress in global child health

As the 2015 deadline to meet the Millennium Development Goals nears, United Nations statisticians say life's improved drastically for children in the developing world. How do they know?
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Leoncia Uwimbabazi and Lea Mukeshimana soothe their babies after vaccination at the Nyamata Health Center in the Bugasera District of Rwanda on September 3, 2010. With big strides made against both malaria and pneumococcal disease, Rwanda is on track to meet UN Millennium Development Goal no 4, the reduction of child mortality, officials say. 'Rwanda is one of the few countries in Africa that stands a chance of reaching the MDG targets if the current rhythm is maintained,' said Lamine Cisse Sarr, World Health Organisation representative to Rwanda. (Shanon Jensen/AFP/Getty Images)

The number of children who get measles vaccinations in Rwanda has been steadily climbing since 2001. But in June of last year, the United Nations reported a sudden drop in coverage from 97 percent to 80 percent.

When Rwandan Minister of Health Agnes Binagwaho saw the statistics show up online, she was certain it couldn’t be true. She posted an indignant Tweet calling out both UNICEF and the World Health Organization: “Why is #Rwanda’s DTP3 vaccine coverage shown as 80% on your sites?”

The vaccination reports, it turns out, said little about the health of Rwanda’s children. Rather, it illustrated the challenges of measuring child health in the developing world.

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Sierra Leone: Where water is foul, diarrhea is a killer

The people here endure the highest under-5 death rate in the world as local politicians and foreign NGOs fail to supply clean water.

FREETOWN, Sierra Leone — In Kroo Bay, a slum located in the heart of Freetown, mounds of raw sewage seep into pools of stagnant water. Children play on doorsteps, and neighbors bathe in the nearby Crocodile River, which feeds into the Atlantic Ocean.

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Malaria tests fate for children living in deadly climate zones

For 4-year-old Edwin, a Zambian, a piece of medical technology common in the West but rare in Zambia made all the difference.

KALENE HILL, Zambia – Edwin could have been my son.

When I first met him I was on assignment in Zambia. So much about Edwin reminded me of my youngest son, Konstantin. They were both 4 years old, and they both had a double set of dimples that pocked their cheeks when they smiled. The simple green t-shirt that Edwin wore looked as if it could have come right out of Konstantin’s drawer. And they both lived near the equator, as I was living with my family in Indonesia at that time.

Despite the similarities, fate for these two boys could not be more different for a specific and tragic reason: Konstantin had access to hospitals, mosquito nets, and a car. Edwin did not.

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India's malnourished children: It's not just about food

As India's government considers landmark legislation to address hunger, economists bicker about the root cause of the country's high malnutrition rates.
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A low wage earning Indian day laborer loads a 60 kg bags of rice on his back at a grains depot near New Delhi on August 27, 2013, one day after the Indian parliament passed a flagship program to provide subsidized food to the poor that is intended to 'wipe out' endemic hunger and malnutrition in the aspiring superpower. Despite decades of fast economic growth, India still struggles to feed its 1.2-billion population adequately with more than 40 percent of children under five malnourished, according to a major survey last year. (Roberto Schmidt/AFP/Getty Images)

India’s lower house of parliament Monday approved an ambitious proposal to address child malnutrition that would provide food at a subsidized rate to nearly two-thirds of the country’s 1.2 billion people.

Congress Party chief Sonia Gandhi told legislators that approving the bill, which aims to give 11 pounds of cheap grain to poor families monthly, was a “message” to the world that India was ready to eradicate malnutrition.

The country's malnutrition rates are among the worst in the world — even worse, the World Health Organization reports, than much more economically disadvantaged countries in sub-Saharan Africa. But is the problem that India’s children don’t have access to food? Or is there more at play?

Columbia University economist Arvind Panagariya recently ignited a passionate debate about the causes of India’s high malnutrition rate with the publication of a controversial paper arguing that Indian children may be smaller than the global average, not because of poor health, but because of genetics.

In the August 24 issue of Economic & Political Weekly, several researchers published papers refuting his claims, pointing instead to behavioral causes such as female disempowerment and the widespread practice of open defecation. One point of agreement in all the back and forth: it’s not just about food.

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Researchers isolate deadliest diarrhea strains — and find a surprise

In the largest study of diarrheal disease to date, researchers found that four pathogens are responsible for the majority of life-threatening diarrhea cases in developing countries. The second most common? The largely ignored parasite cryptosporidium.
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A worker from the NGO Doctors Without Borders examines a sick baby in Gao, in the north of Mali, on February 4, 2013. (Sia Kambou/AFP/Getty Images)

“What can you tell me about diarrhea in your country?”

It should have been a simple question for an official at Mali’s Ministry of Health, but when researchers backed by the Bill & Melinda Gates Foundation first asked it of Dr. Samba Sow a few years ago, his immediate thought, he said, was, “Not much.”

International organizations like UNICEF and the World Health Organization estimate diarrhea is the second most common cause of death for children under 5 in Mali. But, on a local level, the only hard data Sow had to work with at the time was an annual report of the number of children who checked into hospitals showing symptoms of diarrhea.

“If I was just looking at the numbers and considering nothing else, I didn’t know enough to say for sure that we even had a problem,” he said by phone.

The Ministry of Health agreed to make Mali one of seven sites in the Global Enterics Multi-center Study (GEMS), the largest and most in-depth research project examining diarrheal disease in the developing world to date. Sow used the resulting statistics to secure funding for a vaccine against diarrheal disease — among other things. But the findings, recently published in The Lancet, aren’t just helpful to Mali. They’re illuminating for the global health community as a whole.

Diarrhea is a tough problem to solve because it is caused by more than 40 different viruses, bacteria and parasites. GEMS found, though, that just four pathogens are responsible for the majority of moderate-to-severe diarrhea cases. The virus that topped the list — rotavirus — has long been regarded as a formidable foe. But the second most common contributor to diarrheal disease was a parasite called cryptosporidium, which has, up to this point, been considered more of a nuisance than a lethal threat to all but the severely immune compromised. While there is a vaccine for rotavirus, a weapon against cryptosporidium isn’t even in the pipeline.

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Doctors Without Borders pullout: What will become of Somalia's children?

Doctors Without Borders has played an integral part in Somalia's child health care system for more than 20 years. In the wake of the international NGO's decision withdraw from the country this week, other NGOs are scrambling to come up with a plan to fill in the gaps.
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A Somali child suffering from severe acute malnutrition sits in a ward of the Medecins Sans Frontieres NGO in Dadaab in Kenya on July 22, 2011. (Phil Moore/AFP/Getty Images)

Doctors Without Borders' decision to pull out of Somalia this week after 22 years of medical humanitarian work is sobering news for hundreds of thousands of Somalis who relied on the NGO for healthcare, but it could be particularly troubling for children.

The international group, also known as Médecins Sans Frontières (MSF), is withdrawing from the country in response to repeated violent attacks on staff members. It’s too soon to predict exactly how the move will affect children in Somalia, but the sheer volume of child-centered programs that MSF is shutting down leaves little doubt that they will suffer.

MSF runs the capital city’s only pediatric hospital, where — until this week — doctors operated a general ward, an inpatient feeding program and isolation units for measles and acute watery diarrhea. In addition to providing mobile healthcare, the NGO supported a maternity hospital in Jowhar and offered mother and child heath care, including nutrition and vaccinations, in a number of clinics across the country.

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Ugandan scientists breed mosquitoes to fight malaria

Researchers set out to test the latest weapons in the battle against malaria against the live fire of contact with actual mosquitoes
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A community medicine distributor explains how to use anti-malaria medicine to Carolyn Nampera, mother of Elijah Bumba, 14 months, in her house in Kiboga District, Uganda. (Walter Astrada/AFP/Getty Images)

KAMPALA, Uganda — Sometimes you have to breed mosquitoes in order to kill them.

In Uganda, where the mosquito-borne malaria parasite is the country’s leading cause of death, the health ministry must fight on multiple fronts to protect the population. It tests pregnant women for the disease, supplies local health centers with the anti-malarial drug Coartem, and with the support of the Global Fund and USAID, is working on an ambitious campaign to distribute 21 million insecticide-treated bed nets across the country. It has also set up a laboratory in the capital, Kampala, where government scientists breed the tiny bloodsuckers by the thousands.

Their mission: to test the latest weapons in the battle against malaria against the live fire of contact with actual mosquitoes.

“They are very tricky animals, by the way,” said Dr. Myers Lugemwa, the deputy program manager for Uganda’s Malaria Control Programme. Given time to adapt, he said, “they can resist anything.”

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United Nations deemed responsible for Haiti cholera outbreak

A study released last week by Yale University traces Haiti's strain of cholera back to a strain brought by Nepalese peacekeepers.
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November 15, 2012- People lay in beds as Haitian health authorities deplored a resurgence of cholera after Hurricane Sandy, according to MSF (medecins sans frontieres), with aid tents set up in Delmas, a suburb of Port-au-Prince. (THONY BELIZAIRE/AFP/Getty Images)

Just months after the colossal January 2010 earthquake devastated Haiti, the country was stricken by another human catastrophe that would come to claim the lives of over 8,000 people: the outbreak of a cholera epidemic.

After years of investigation and controversial suspicions, a new Yale study is holding the United Nations accountable for what was the first cholera outbreak in Haiti in over 100 year, and what has become the largest in the epidemic world.

“Peacekeeping Without Accountability” reports that over 600,000 people fell ill UN peacekeeping troops inadvertently carried the disease from Nepal, where cholera is endemic, to
 the Haitian town of Méyè.

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Malnutrition is an unspoken diagnosis in India's pediatric hospitals

The children in India's hospitals officially check in for a variety of reasons — diarrhea, pneumonia, skin disease. But most have one thing in common.
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(Emily Judem/GlobalPost)

Editor's Note: This is the fifth in a series of posts about child health in India, where, in 2011, 1.7 million children under the age of 5 died. Health reporting fellow Harman Boparai travels to India, where he once practiced as a physician, to take a deeper look at child health in his home country. "A Doctor's Notes" is part of a GlobalPost Special Report titled "The Seven Million," about the many challenges faced worldwide in an effort to reduce child mortality.

 

PANNA and NEW DELHI, India — The pediatric ward at Panna District Hospital was cramped with the bustling crowd of patients and their families. Not a single bed was empty. Three-year old Deeksha, in the hospital for the seventh day, was two beds away from the door.

With sunken eyes and shriveled skin, she lay listless next to her mother amid all the commotion. She weighed barely 15 pounds, and had been diagnosed with chronic diarrhea as well as primary tuberculosis.

Directly opposite Deeksha lay another 3-year-old, Chandini. At 16 pounds, she was also severely underweight, and suffered from a skin infection. I walked with Dr. LK Tiwari, the only pediatrician in the district, as he took his rounds. The families of the children stood expectantly as he went from one bed to the next, just a foot or two apart from each other.

The children suffered from different ailments and came from different villages. But most all of them had one thing in common: they were severely undernourished. Malnutrition is so common at Panna District Hospital that the staff takes it for granted.

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Already an unlikely success story, Liberia boosts efforts to end child death

Liberia recently launched an aggressive new health plan as part of an international movement to end preventable child deaths.
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A sick child awaits treatment on his bed at the Phebe hospital near Gbarnga on December 4, 2008. (Georges Gobet/AFP/Getty Images)

Ten years after the end of Liberia's civil war, the infrastructure is still in shambles, and there's a shortage of both health workers and money to pay them. But in spite of it all, the government recently rolled out an aggressive new plan to end preventable child deaths.

The country is one of the first to introduce a detailed plan of action to address child survival as part of a worldwide initiative launched in 2012 by the United States, India, Ethiopia and the United Nations Children’s Fund. More than 176 countries have joined the movement, called “Committing to Child Survival: A Promise Renewed,” pledging to redouble efforts to meet the 2015 deadline for the UN Millennium Development Goal to cut child mortality to two-thirds of the 1990 rate. By 2035, the countries have vowed to reduce the under-five death rate to 2 of 100 live births or fewer.

Liberia's optimism is rooted in a record of beating the odds: Liberia has improved child survival rates faster than any other African nation, cutting deaths by an average of 5.4 percent a year. In 1990, nearly a quarter of Liberian children never lived to see their fifth birthday, according to UNICEF. By 2010, that number had dropped 68 percent. It is one of just a handful of African countries to achieve the Millennium Development Goal ahead of deadline.

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