Presentazione

da "www.nytimes.com"

By CELIA W. DUGGER
Published: September 9, 2009

MPATA, Malawi — The number of children dying before their fifth birthdays each year has fallen below nine million for the first time on record, a significant milestone in the global effort to improve children’s chances of survival, particularly in the developing world, according to data that Unicef will release on Thursday.

The child mortality rate has declined by more than a quarter in the last two decades — to 65 per 1,000 live births last year from 90 in 1990 — in large part because of the widening distribution of relatively inexpensive technologies, like measles vaccines and anti-malaria mosquito nets.

Other simple practices have helped, public health experts say, including a rise in breast-feeding alone for the first six months of life, which protects children from diarrhea caused by dirty water.

Wealthy nations, international agencies and philanthropists like Bill and Melinda Gates have committed billions of dollars to the effort. Schoolchildren and church groups have also pitched in, paying for mosquito nets and feeding programs.

Taken together, they have helped cut the number of children under 5 who died last year to 8.8 million — the lowest since records were first kept in 1960, Unicef said — from 12.5 million in 1990.

“That’s 10,000 less children dying per day,” said Unicef’s executive director, Ann M. Veneman.

Even so, there is still a long way to go before achieving the goal set by leaders of 189 nations in 2000: to cut the child mortality rate by two-thirds by 2015. Pneumonia and diarrhea, the two leading causes of child deaths, are still relatively neglected, especially compared with malaria and measles, experts say.

“If we say as a world we care about saving children, and tackle the problem systematically, piece by piece, we can make progress, and it’s really important for people to know that,” Mrs. Gates said in an interview.

One of the most vertiginous drops in child mortality has occurred here, in a country so poor that half the children are stunted by malnutrition, so bereft of doctors and nurses that workers with 10th-grade educations dispense antibiotics. Yet for every 1,000 babies born here, 125 more children survived to their fifth birthdays in 2008 than did in 1990, the new figures show.

Malawi’s success and that of nations across the developing world was not inevitable. South Africa, the richest country in sub-Saharan Africa but afflicted with what its scientists and doctors describe as flawed political leadership on health policy over the past decade, is one of only four nations that experienced a rise in mortality rates for children under age 5 from 1990 to 2008. The others are Chad, Congo and Kenya, according to the new figures, which stem from an analysis of household surveys and other data by Unicef, the World Health Organization, the World Bank and the United Nations population division.

Malawi illustrates the essence of the most successful efforts to reduce child mortality: it has found many creative ways to get the most cost-effective treatments and prevention methods to women and children, even in remote rural areas. Those interventions have included not just mosquito nets and vaccinations, but also deworming medicines and vitamin A supplements that boost children’s immunity.

Perhaps Malawi’s most powerful weapon is its ranks of more than 10,000 high school-educated village health workers. With a minimum 10 weeks of training, medical checklists to aid them in diagnosing childhood killers and hardy bicycles to get around, they dispense medicines and give injections, tasks only doctors and nurses do in many other countries.

“These days, when a child falls sick in the night, the mother can knock on the door of the health assistant,” said Teresa Frazier, 40. Her own 5-year-old daughter died after falling violently ill one night when Ms. Frazier was a young mother in a Malawian village of mud huts that, at the time, was many miles from the nearest medical help.

But as the sun went down on Monday, Ms. Frazier walked up to the tiny, two-room home of Blessings Mwaraya, 27, a health worker who lives amid banana, avocado and mango trees. Ms. Frazier, who gave birth to nine children, seven of whom survived, said she could not manage any more.

She had come for an injection of Depo Provera for birth control. Mr. Mwaraya, who earns $90 a month, painstakingly shook the little glass bottle containing the solution, drew it into the needle and stuck it in her arm. Health experts say family planning enables women to space births apart and have fewer children, aiding them in bearing healthier babies and better providing for them as they grow up.

“It’s still difficult to feed them all,” Ms. Frazier said of her surviving children, noting the paltry yield of corn on her small plot. Had Mr. Mwaraya been in the village in her younger days, she would have chosen to have had only four children, she said.

Mr. Mwaraya kept the Depo Provera in a plain wooden box, divided into compartments also stuffed with treatments for the main childhood killers: cotrimoxazole, a low-cost antibiotic, against pneumonia; oral rehydration salts for diarrhea; and Coartem, medicine for malaria.

“My interest was to assist my fellow Malawians who were falling sick but never had treatment at the village level,” said Mr. Mwaraya, dressed in a uniform of light blue pants and a short-sleeve jacket.

The pace of progress in Malawi and six other countries with some of the highest proportions of children dying — Nepal, Bangladesh, Eritrea, Laos, Mongolia and Bolivia — has been much steeper than the global average, the new data show. In each, child mortality rates have fallen at least 4.5 percent annually.

Here in Malawi, the mortality rate for children under 5 fell to 100 deaths per 1,000 births in 2008 from 225 in 1990 and 336 in 1970. Other poor nations, like Niger, Mozambique and Ethiopia, have also cut the number of deaths per 1,000 births by more than 100 since 1990, according to the new figures.

Doris Hebuye, a thin, sociable woman, listened from a distance one morning as her daughter Fanny, a new mother, cradled her 10-day-old baby. A health worker counseled Fanny Kasipati, 18, on the finer points of breast-feeding, the danger signs of sickness and choices for birth control.

As she sat outside their mud hut in the village of Tetheleya, Mrs. Hebuye’s eyes had a sad, faraway look as she described the deaths of two of her seven children — Gustus, at 3, and Margaret, at 1 —from causes she had never really understood.

“Malawi is changing for the better,” she said. “In those days, people gave birth without advice. These days, women are assisted in many ways.”