3.3 Surviving in Good Health

Although precise worldwide statistics are unavailable, at least 10 billion children were born between 1950 and 2010. More than 2 billion of them died before age 5 years. Although 2 billion is far too many, twice as many would have died without recent public health measures. As best we know, in earlier centuries more than half of all newborns died in infancy.

Better Days Ahead

In the twenty-first century, 99.9 percent of newborns in developed nations who survive the first month (when the sickest and smallest may die) live to adulthood. Even in the poorest nations, where a few decades ago many children died before age 5 years, now about 80 percent live (see TABLE 3.1).

Well Protected Disease and early death are common in Africa, where this photo was taken, but neither is likely for 2-year-old Salem. He is protected not only by the nutrition and antibodies in his mother’s milk, but also by the large blue net that surrounds them. Treated bed nets, like this one provided by the Carter Center and the Ethiopian Health Ministry, are often large enough for families to eat, read, and sleep in together, without fear of malaria-infected mosquitos.

LOUISE GUBB/CORBIS

The world death rate in the first five years of life has dropped about 2 percent per year since 1990 (Rajaratnam et al., 2010). Most nations have improved markedly on this measure since 1990. Only when war destroys families and interferes with public health measures (as it has in Afghanistan) are nations not improving this statistic.

Public health measures (clean water, nourishing food, immunization) are the main reasons for the higher rate of survival. When women realize that a newborn is likely to survive to adulthood, they have fewer babies, and that advances the national economy. Infant survival and maternal education are the two main reasons the world’s 2010 fertility rate is half what the rate was in 1950 (Bloom, 2011; Lutz & Samir, 2011).

If doctors and nurses were available in underserved areas, the current infant death rate would be cut in half—immediately by newborn survival and widespread immunization, and soon via measures to help the whole population, such as better food distribution, less violence, and clean water (Farahani et al., 2009). For example, every year in Africa 1 million people die of malaria, most of them undernourished children. Immediate drug treatment can save lives, but many victims live far from medical help, and some anti-malaria drugs are no longer effective (Kun et al., 2010).

One innovation has cut the malaria death rate in half: bed nets treated with insect repellant that drape over sleeping areas (Roberts, 2007) (see photo). Over the long term, however, systemic prevention means making mosquitos sterile—a promising research effort now entering clinical trials (James et al., 2011).

Immunization

Immunization primes the body’s immune system to resist a particular disease. Immunization (also called vaccination) is said to have had “a greater impact on human mortality reduction and population growth than any other public health intervention besides clean water” (J. P. Baker, 2000).

No immunization is yet available for malaria. Thousands of scientists are working to develop one, and some clinical trials seem promising (Vaughan & Kappe, 2012). However, immunization has been developed for measles, mumps, whooping cough, smallpox, pneumonia, polio, and rotavirus, which no longer kill hundreds of thousands of children each year.

It used to be that the only way to become immune to these diseases was to catch them, sicken, and recover. The immune system would then produce antibodies to prevent recurrence. Beginning with smallpox in the nineteenth century, doctors discovered that giving a vaccine—a small dose of the virus—to healthy people who have not had the disease stimulates the same antibodies.

Specific DiseasesStunning successes in immunization include the following:

• Smallpox, the most lethal disease for children in the past, was eradicated worldwide as of 1971. Vaccination against smallpox is no longer needed.

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• Polio, a crippling and sometimes fatal disease, is rare. Widespread vaccination, begun in 1955, eliminated polio in the Americas. Only 784 cases were reported anywhere in the world in 2003. In the same year, however, rumours halted immunization in northern Nigeria. Polio reappeared, sickening 1948 people in 2005, almost all in West Africa. Then public health workers and community leaders campaigned to increase immunization, and Nigeria’s polio rate plummeted. Meanwhile, poverty and new conflicts in South Asia prevented immunization (De Cock, 2011; World Health Organization, 2012a). Worldwide, 223 cases were reported in 2012. In 2013, only three countries, Afghanistan, Nigeria, and Pakistan, had an epidemic of polio (World Health Organization, 2013a). Since 1988, there has been a 99 percent decrease in cases (See Figure 3.6).
  

  FIGURE 3.6 Not Yet Zero Many public health advocates hope polio will be the next infectious disease to be eliminated worldwide, as is the case in almost all of North America. The number of cases has fallen dramatically worldwide (a). However, there was a discouraging increase in polio rates from 2003 to 2005 (b).
• Measles (rubeola, not rubella) is disappearing, thanks to a vaccine developed in 1963. Prior to that time, about 300 000 children were affected by measles each year in Canada alone. About 300 of these children died each year and another 300 suffered permanent brain damage. After the introduction of the measles vaccine, the number of cases dropped dramatically to about 50 a year (Public Health Agency of Canada, 2014).

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• Canada began publicly funding a vaccination program for varicella (chicken pox) in 2004. Since then, hospitalization rates for varicella dropped from an average of 288 per year to 114 per year (Public Health Agency of Canada, 2012c).

Immunization protects children not only from temporary sickness, but also from complications, including deafness, blindness, sterility, and meningitis. Sometimes the damage from illness is not apparent until decades later. Childhood mumps, for instance, can cause sterility and doubles the risk of schizophrenia (Dalman et al., 2008).

Some people cannot be safely immunized, including the following:

• Embryos, who may be born blind, deaf, and brain-damaged if their pregnant mother contracts rubella (German measles)
• Newborns, who may die from a disease that is mild in older children
• People with impaired immune systems (HIV-positive, aged, or undergoing chemotherapy), who can become deathly ill.

Fortunately, each vaccination of a child stops transmission of the disease and thus protects others, a phenomenon called herd immunity. Although specifics vary by disease, usually if 90 percent of the people in a community (a herd) are immunized, the disease does not spread to those who are vulnerable. Without herd immunity, some community members die of a “childhood” disease.

Problems With ImmunizationSome infants react to immunization by being irritable or even feverish for a day or so, to the distress of their parents. In addition, many parents are concerned about the potential for even more serious side effects. Whenever something seems to go amiss with vaccination, the media broadcasts it, which frightens parents. As a result, the rate of missed vaccinations has been rising over the past decade. This horrifies public health workers, who, taking a longitudinal and society-wide perspective, are convinced that the risks of the diseases are far greater than the risks from immunization. A hypothesis that the MMR (measles-mumps-rubella) vaccine causes autism has been repeatedly disproved (Mrozek-Budzyn et al., 2010; Shattuck, 2006). (More on autism in Chapter 7.)

True Dedication This young Buddhist monk lives in a remote region of Nepal, where, until recently, measles was a fatal disease. Fortunately, a UNICEF porter carried the vaccine over mountain trails for two days so that this boy—and his whole community—could be immunized.

SCOTT EELLS/THE NEW YORK TIMES/REDUX

Doctors agree that vaccines “are one of the most cost-effective, successful interventions in the history of public health” and lament that that success has made parents, physicians, and governments less vigilant (Hannan et al., 2009, p. S571). For example, lack of immunization is blamed for a spike in infant whooping cough cases across Canada in 2012.

Nutrition

Infant mortality worldwide has plummeted in recent years. Several reasons have already been mentioned: fewer sudden infant deaths (explained in Chapter 1), advances in prenatal and newborn care (explained in Chapter 2), and, as you just read, immunization. One more measure has made a huge difference: better nutrition.

Breast is BestIdeally, nutrition starts with colostrum, a thick, high-calorie fluid secreted by the mother’s breasts at birth. After about three days, the breasts begin to produce milk. Compared with formula based on cow’s milk, human milk is sterile, always at body temperature, and rich in iron, vitamins, and other newly discovered nutrients for brain and body (Drover et al., 2009).

Same Situation, Far Apart: Breastfeeding Breastfeeding is universal. None of us would exist if our foremothers had not successfully breastfed their babies for millennia. Currently, breastfeeding is practised worldwide, such as shown here in Laos and Canada. It is no longer the only way to feed infants, and each culture has particular practices.

ALAIN EVRARD/ROBERT HARDING
SELECTSTOCK/GETTY IMAGES

Babies who are exclusively breastfed are less often sick. In infancy, breast milk provides antibodies against any disease to which the mother is immune and decreases allergies and asthma. Disease protection continues throughout life, because babies who are exclusively breastfed for 6 months are less likely to become obese (Huh et al., 2011) and thus less likely to develop diabetes and heart disease.

Breast milk is especially protective for preterm babies; if a preterm baby’s mother cannot provide breast milk, physicians recommend milk from another woman (Schanler, 2011). (Once a woman has given birth, her breasts produce milk for decades if they continue to be stimulated.) In addition, the specific fats and sugars in breast milk make it more digestible and better for the brain than any substitute (Drover et al., 2009; Riordan, 2005). (See TABLE 3.2 for other benefits of breast milk.)

The composition of breast milk adjusts to the age of the baby, with milk for premature babies distinct from that for older infants. Quantity increases to meet the demand: Twins and even triplets can grow strong while being exclusively breastfed for months.

Not all mothers are able to breastfeed as some may have health conditions or take medication that could harm the infant. Formula feeding is preferable only in unusual or challenging cases, such as when the mother is HIV-positive or uses toxic or addictive drugs. Even then, however, breast milk may be advised. In some African nations, HIV-positive women are encouraged to breastfeed because their infants’ risk of catching HIV from their mothers is lower than the risk of dying from infections, diarrhea, or malnutrition as a result of bottle-feeding (Cohen, 2007b; Kuhn et al., 2009).

Doctors worldwide recommend breastfeeding with no other foods—not even juice. Some pediatricians suggest adding foods (rice cereal and bananas) at 4 months; others want mothers to wait until 6 months (Fewtrell et al., 2011). For breast milk to meet the baby’s nutritional needs, the mother must be well-fed and hydrated (especially important in hot climates) and should avoid alcohol, cigarettes, and other drugs.

Breastfeeding was once universal, but by the middle of the twentieth century many mothers thought formula feeding was more modern. Fortunately, that has changed again. In 2005, the Canadian Paediatric Society (CPS) began recommending that newborn infants be exclusively breastfed for the first 6 months (Boland, 2005). By 2009, 87 percent of Canadian mothers were breastfeeding their most recent baby for at least a short period of time. In the same year, just under 25 percent of mothers were following the CPS recommendation and exclusively breastfeeding their infants for at least six months (see Figure 3.7) (Statistics Canada, 2011b).

FIGURE 3.7 A Smart Choice Midway through the twentieth century, educated women in North America were taught that formula was the smart, modern way to provide nutrition—but no longer. Today, more education for women correlates with more breast milk for babies. In 2009, 27 percent of Canadian women with a post-secondary degree or diploma breastfed exclusively for 6 months—no juice, no water, and no cereal. This was about 3 percentage points higher than the national average for that year.

Although statistics for breastfeeding of Aboriginal children have some serious limitations, one earlier survey found that 73 percent of off-reserve Aboriginal children aged 3 months and younger were breastfed. Although this is lower than the national average, it still represents an upward trend (Turcotte & Zhao, 2004).

Worldwide, about half of all 2-year-olds are still nursing, usually at night. How long a mother breastfeeds is strongly affected by her experiences in the first week, when encouragement and practical help are most needed (DiGirolamo et al., 2005). Ideally, nurses visit new parents weekly at home; such visits (routine in some countries, rare in others) increase the likelihood that breastfeeding will continue.

MalnutritionProtein-calorie malnutrition occurs when a person does not consume sufficient food to sustain normal growth. That form of malnutrition occurs for roughly one-third of the world’s children in developing nations: They suffer from stunting, being short for their age because chronic malnutrition prevented them from growing (World Bank, 2010). Stunting is most common in the poorest nations (see Figure 3.8).

FIGURE 3.8 Genetic? The data show that basic nutrition is still unavailable to many children in the developing world. Some critics contend that Asian children are genetically small and therefore Western norms make it appear as if India and Africa have more stunted children than they really do. However, children of Asian and African descent born and nurtured in North America are as tall as those of European descent. Thus, malnutrition, not genes, accounts for most stunting worldwide.

Even worse is wasting, when children are severely underweight for their age and height (two or more standard deviations below average). Many nations, especially in East Asia, Latin America, and central Europe, have seen improvement in child nutrition in the past decades, with an accompanying decrease in wasting and stunting.

In some other nations, primarily in Africa, wasting has increased. And in several nations in South Asia, about half the children over age 5 years are stunted and half of them are also wasted, at least for a year (World Bank, 2010). In terms of development, the worst effect is that energy is reduced and normal curiosity is absent (Osorio, 2011).

One common way to measure a particular child’s nutritional status is to compare weight and height with the detailed norms presented in Figures 3.1 and 3.2. For example, a sign of poor nutrition would be a long child who doesn’t weigh a lot (underfeeding) or a short child who weighs a lot (overfeeding), as compared to the norms. Remember that some children may simply be genetically small, but all children should grow rapidly in the first two years.

Chronically malnourished infants and children suffer in three ways (World Bank, 2010):

1. Their brains may not develop normally. If malnutrition has continued long enough to affect height, it may also have affected the brain.
2. Malnourished children have no body reserves to protect them against common diseases. About half of all childhood deaths occur because malnutrition makes a childhood disease lethal.
3. Some diseases result directly from malnutrition, such as marasmus during the first year, when body tissues waste away, and kwashiorkor after age 1, when growth slows down, hair becomes thin, skin becomes splotchy, and the face, legs, and abdomen swell with fluid (edema).

Prevention, more than treatment, stops childhood malnutrition. In fact, some children hospitalized for marasmus or kwashiorkor die even after feeding, because their digestive systems are already failing. Prevention starts with prenatal nutrition and breastfeeding, with supplemental iron and vitamin A for mother and child.

A study of two poor African nations (Niger and Gambia) found several specific factors that reduced the likelihood of wasting and stunting: breastfeeding, both parents at home, water piped to the house, a tile (not dirt) floor, a toilet, electricity, immunization, a radio, and the mother’s secondary education (Oyekale & Oyekale, 2009). Overall, “a mother’s education is key in determining whether her children will survive their first five years of life” (United Nations, 2011).

Poverty and NutritionPoverty has strong and well-documented negative impacts on nutrition and brain development in infants and young children. Its effects are not limited to nations in Africa and Asia; childhood poverty is a widespread and stubborn problem in Canada, too. This problem has grown worse over the past 20 years, despite the federal government’s announced commitment in 1989 to eliminate poverty among children by the year 2000. In 2010, 979 000 or 14.5 percent of all Canadian children were living in poverty. Among Aboriginal peoples in Canada, the childhood poverty rate stands at a very troubling 25 percent (Campaign 2000, 2011).

Poor nutrition, often resulting from poverty, has been directly linked to lower scores on tests of vocabulary, reading comprehension, arithmetic, and general knowledge. Poor nutrition in infancy can also have negative impacts on a child’s physical growth and motor skill development, and it can affect a child emotionally, resulting in a withdrawn or mistrustful personality (Brown & Pollitt, 1996).

Other risk factors for children in poverty include maternal drug abuse and depression. Specifically, substance abuse by a pregnant woman can stunt the growth of neurons in her baby’s brain and lead to serious neurological disorders (Jones, 1997). Depressed mothers affect their infants’ brain development because they are less likely to provide the stimulation babies need at critical points in their growth. This can result in children who are less active and have shorter attention spans (Belle, 1990).

Finally, children living in poverty are more likely to experience the chronic and elevated levels of stress that produce the hormone cortisol, which in large doses kills brain cells. This has negative impacts on memory and emotional development and on a child’s ability to concentrate (Gunnar, 1998).

Same Situation, Far Apart: Children Still Malnourished Infant malnutrition is common in nations at war, like Afghanistan (right), or with crop failure, like Niger (left). UNICEF relief programs reach only half the children in either nation. The children in these photographs are among the lucky ones who are being fed.

AP PHOTO/SCCHALK VAN ZUYDAM
DANG NGO/ZUMA PRESS/NEWSCOM