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Strengthening maternal and child health programmes through primary health care. Guidelines for countries of the Eastern Mediterranean Region. Based on the deliberations of the Intercountry Meeting on the Integration of MCH into Primary Health Care, Amman, Jordan, 11-15 December 1988.
Alexandria, Egypt, WHO, EMRO, 1991. 75 p. (WHO EMRO Technical Publication No. 18)All countries in the WHO Eastern Mediterranean Region (EMRO) have had maternal and child health (MCH) programs for many years, yet maternal mortality and morbidity and infant mortality remain high. The EMRO office in Jordan, recognizing this dilemma, convened a meeting of national managers from the 22 EMRO member states to discuss how to integrate MCH programs with primary health care (PHC). The meeting resulted in the publication of guidelines and goals to help each country integrate MCH into PHC which would strengthen MCH services and improve MCH status. The managers noted the need to switch from a pregnancy-oriented approach to a holistic approach in which MCH/PHC programs and society consider women as more than childbearers. MCH/PHC programs and society need to be concerned about the well-being of females beginning with infancy and should place considerable health promotion for girls during the pubertal spurt and adolescence. They should also promote prevention of iron deficiency anemia in women. Since maternal mortality is especially high is EMRO, the national managers clearly laid out approaches for health services to reduce maternal mortality caused by obstetrical complications. They also recognized the need for a practical alternative to obstetric care provided by health workers--training traditional birth attendants in each village. They also provided guidance on improving prenatal care to reduce perinatal and neonatal mortality such as vaccination of every pregnant woman with the tetanus toxoid. Since the causes of death in the postneonatal period, MCH/PHC programs need to take action to reduce malnutrition and infection. For example, they must promote breast feeding for at least the first 6 months of life. The managers suggested the implementation of the Child Survival and Development Strategy which includes growth monitoring.
POPULATION AND DEVELOPMENT REVIEW. 1991 Dec; 17(4):749-51.The report of the Secretary General of the UN on the social and economic conditions in Africa notes the worsening of conditions during 1986-90. Declines were apparent in education, health, nutrition, employment, and income. Government spending on health declined from 6% in 1985 to 5% in 1990 and on education from 15% to 11%. School enrollment declined from 77% in 1980 to 72% in 1987 and 70% in 1990. Primary school enrollments were also affected; i.e., only 65% of those enrolled in 1986 were still in school in 1990. Illiteracy rates dropped from 59.1% in 1985 to 52.7% in 1990, but the absolute numbers rose from 133.6 million to 138.8 million. Female illiteracy is very high at 66% compared to 46% for males. Government funding cuts have also had an impact on nutrition. There were 70 million more severely undernourished Africans in 1989 than in the mid 1970s (80 million), and 40% of preschool children suffered from acute protein energy deficiency, which is an increase of 25% from 1985. There was evidence of large numbers of underweight (26.6%), wasting (10.2%), and stunted children )53.3%). Diseases such as malaria, trypanosomiasis, and schistosomiasis, which had been under control or eradicated reappeared. The <5 years mortality rate remained stable and high at 182/1000. Improvements have been made in expansion of immunization, 22 countries achieved 75% immunization in 1990. There were fewer deaths from measles and diarrheal diseases. Maternal mortality remains high at 1120/1000. AIDS is a serious social problems. By 1991, 6 million people had been infected with HIV including 3 million women an increases are expected. 900,000 HIV-infected babies were born as of 1990. The number of AIDS orphans is increasing. Real wages declined by 30% during the 1980s, and unemployment grew an average of 10%/year between 1986-90. Formal sector employment stagnated, and informal sector employment showed tremendous increases. Substance farming became a survival strategy. Poverty has affected as much as 50% of the African population. Brain drain emigration has resulted in the loss of an estimated 50-60,000 people. For Africa, the future emphasis will be on efficacy, tough minded realism, self-reliance, and grassroots initiatives.
Improving food security at household level; government, aid and post-drought development in Kordofan and Red Sea Hills.
In: To cure all hunger. Food policy and food security in Sudan, edited by Simon Maxwell. London, England, Intermediate Technology Publications, 1991. 218-31.The question whether government, assisted by aid, is capable of targeting interventions to those lacking food security is examined. Food security is a general concept which includes security against seasonal fluctuations, long-term declines in the natural resource base, and economic conditions which lead to destitution. Food security is analyzed at individual, household, community, regional, national, and international levels. Household interventions are also concerned with intra-household distribution and the level of community security. Food-insecure rural women and children in marginal drought-prone areas were the focus of programs funded by UNICEF in Sudan: the Joint Nutrition Support Project (JNSP) in Red Sea Hills (1983-88) and the Integrated Women's Development Program (IWDP) in Kordofan (1987-91). These multi-sectoral programs were carried out by departments of regional and provincial government along with the reactions to famine. In both Kordofan and Red Sea Hills extreme poverty is widespread, with high vulnerability to food insecurity which is even higher in Red Sea Hills. In Red Sea Hills, UNICEF/WHO had negotiated the 5-year JNSP to cover the province just as the famine broke in 1983/84. In Kordofan, UNICEF collected baseline data on such indicators and then returned after a two-year period to communities originally surveyed for monitoring. In Red Sea Hills, JNSP's target population were the food-insecure nomads. The Department of Health structure became sufficiently strong, at least partly due to 5 years of investment and development of primary health care personnel under JNSP. The department represents the best administrative mechanism in the province for the development of famine early-warning systems. Many food-security measures in Red Sea Hills are experimental and wrought with difficulty, thus the existence of a relatively strong administration will favor a food security strategy based on primary health care interventions.
In: To cure all hunger. Food policy and food security in Sudan, edited by Simon Maxwell. London, England, Intermediate Technology Publications, 1991. 15-48.The concept of National Food Security Planning (NFSP) emerged following the famine of 1972-74 and the World Food Conference of 1974. NFSP did not prove to be a cure-all in the 4 countries which the European Community (EC) adopted on a trial basis or in the many other countries later. NFSP did not produce a substantial increase in aid from the rich countries, but it did raise aid conditionally. Sudan has a total area of 2.5 million sq. km of which only 32% is cultivable. Agricultural potential is concentrated in irrigable areas in north Sudan, in the plains of the center of the country, and in the higher rainfall areas of the 3 southern regions. Per capita income is stagnant, infant mortality was 108/1000 in 1988, and life expectancy reached only 50. International Labor Organization statistics showed that income worsened with the poorest 40% of the population earning 16% of total income in 1967-68 compared with only 12% in 1978-79. In Northern Sudan 12.6% of children were stunted in 1986-87 and 12.7% wasted particularly in North and South Darfur and in Khartoum. World Bank data disclosed that up to 18% of the population regularly faced serious food problems. A national survey was carried out from May 1986 to July 1987 on the nutritional status of children under 5 years of age measuring weight for height. Almost 13% of children were malnourished. These data also implied that about 2.3 million people were undernourished in north Sudan in 1988. Since all poor people are vulnerable to food insecurity, one-half of the population or about 9 million people in north Sudan were subject to food insecurity in 1988. The EC, the World Bank, and the UN Food and Agricultural Organization are deeply involved in NFSP, while USAID is waiting. Comparison with other countries in sub-Saharan Africa suggests that the scale of intervention should be reduced but greater efforts should be made to benefit poor producers and consumers.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1991; 69(6):779-89.5-15% of all 3-15 year old children in the world are mentally impaired. In fact, 0.4-1.5% (10-30 million) are severely mentally retarded and an additional 60-80 million children are mildly or moderately mentally retarded. Birth asphyxia and birth trauma account for most cases of mental retardation in developing countries. >1.2 million newborns survive with severe brain damage and an equal number die from moderate or severe birth asphyxia. Other causes of mental retardation can also be prevented or treated such as meningitis or encephalitis associated with measles and pertussis; grave malnutrition during the 1st months of life, especially for infants of low birth weight; hyperbilirubinemia in neonates which occurs frequently in Africa and countries in the Pacific; and iodine deficiency. In addition, iron deficiency may even slow development in infants and young children. Current socioeconomic and demographic changes and a rise in the number of employed mothers may withhold the necessary stimulation for normal development from infants and young children. Primary health care (PHC) interventions can prevent many mental handicaps. For example, PHC involves families and communities who take control of their own care. Besides traditional birth attendants, community health workers, nurse midwives, physicians, and other parents must also participate in prevention efforts. For example, they should be trained in appropriate technologies including the risk approach, home risk card, partograph, mouth to mask or bag and mask resuscitation of the newborn, kick count, and ictometer. WHO has field tested all these techniques. These techniques not only prevent mental handicaps but can also be applied at home, health centers, and day-care centers.
In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 119-21.This article is an overview of comprehensive up-to-date accounts of the current literature on infective and parasitic diseases and malnutrition found in part II of the 1991 World Bank publication entitled Disease and Mortality in Sub-Saharan Africa. It also points out that the region has a problem with insufficient health information systems and lack of surveillance. Malaria is still a major cause of morbidity and mortality in Sub-Saharan Africa. Further the mosquito vectors become resistant to insecticides and the parasite becomes resistant to drugs. It poses many challenges to epdiemiologists, malariologist, pharmacologists, and immunologists. Yet there are not enough of African malaria scientists to address these problems. Diarrhea remains a leading cause of morbidity and mortality in small children in Sub-Saharan Africa. It includes the dysenteries, typhoid, other salmonella infections, cholera, and intestinal parasitic infections such as hookworm and ascaris. Countries in Sub-Saharan Africa need to emphasize good hygiene, safe excreta disposal, and safe water supply to prevent these conditions. Another major cause of disease and mortality in children is acute respiratory infections (ARIs) such as pneumonia. Antibiotics can treat some of these ARIs. WHO's Expanded Programme on Immunization (EPI) operates in many Sub-Saharan African countries and coverage is often high. For example, the Gambia has reached 80% coverage in children <2 years old with measles, DPT-3, BCG, polio-3, and yellow fever. Yet the 6 disease of EPI continue to afflict children. The AIDS epidemic exacerbates the burden of Sub-Saharan Africa which is already fraught with disease. Children in Sub-Saharan Africa also bear a nutritional burden (40% prevalence of stunting and 9% of wasting). Further many children also suffer from micronutrient deficiencies such as vitamin A. Other health problems in Sub-Saharan Africa include leprosy, meningococcal meningitis, and physical handicaps.
INTER-AMERICAN PARLIAMENTARY GROUP ON POPULATION AND DEVELOPMENT. BULLETIN. 1991 Dec; 8(11):1-3.The author indicts World Bank, International Monetary Fund, and overall developed country policy as responsible for Latin America's large impoverished and disenfranchised child and adolescent population. As an example of the magnitude of the problem, he notes that 1/3 of Brazil's 150 million population is comprised of youth and children. 8 million live on the streets, of which only 1 million receive official aid. Forced to fend for themselves, these youths fall into drug addiction, prostitution, and crime, suffering poor health, malnutrition, and widespread illiteracy. Many are sold, imprisoned, kidnapped, and exploited. Street children in Rio de Janeiro even suffer the added threat of being killed by the Squadrons of Death who consider the murder of juveniles a solution to delinquency. The state of affairs has deteriorated to such an extent in Peru that abandoned children are considered the most significant social problem. Argentina, Bolivia, Haiti, Honduras, Guatemala, and Nicaragua all suffer similar problems of impoverished youths, and claim some of the highest infant mortality rates (IMR) in the world. Cuba is the only country in Latin America with an IMR comparable to and often lower than many developed countries. Chile and Costa Rica follow closely behind in their achievements. Where Latin America already holds the largest gap between wealthy and poor, meeting adjustment demands of Northern economies and countries has only made conditions and inequities worse. Recession and poverty have worsened at the expense of youths. Attempting to pay down debt over the 1980s, improvements in Latin America's trade balance have gone unnoticed as the South has grown to be a net exporter of capital. Latin American nations need more than token charitable donations in times of emergency and particular duress. Development programs sensitive to the more vulnerable segments of society, and backed by the political will of developed nations, are called for. Unless constructive, supportive policy is enacted by Northern nations to help those impoverished in the South, social rebellion and continued, enhanced resistance should be expected from Latin American youths in the years ahead.
PEOPLE. 1991; 18(1):9-13.The World Resources Institute article provides a discussion of some of the problems facing African farmers, the interaction between population growth and environmental degradation and food production, and the solution in terms of an Environmental Action Plan (EAP) with the specific example of Rwanda. Data were based mainly on the World Bank's The Environment, Agriculture, and Environmental Nexus in Sub-Saharan Africa. The population increased 3.1% in 1980-87 from 2.6% in 1967-73. Deforestation is exceeding reforestation by a factor of 30; expansion of land under cultivation has increased to a rate of 3% a year. Africa is the only developing region with a decline in per capita food production. Yields are declining. 80% of land is affected by decertification, and the production of cereal grains lags behind population needs by 10 million tons with the projection to 2020 of 245 millions tons, an amount greater than the total world trade in cereals. A solution, for example, lies in the restoration of lost resources and increasing crop yields with better resource management techniques (reclaiming swamp land) - all in tandem with the promotion of family planning. It is also important to address the root cause of malnutrition, poor health status, low incomes and lack of educational opportunity. The integrated approach in the case of Rwanda's EAP involved multi-disciplinary groups.