State of the world's children, 1985.

The State of the World's Children reports for 1982 and 1983 drew worldwide attention to the fact that just four relatively simple and inexpensive methods could enable parents in the developing world to save the lives of at least half the 40,000 children who die every day.

Those methods are:

* Oral rehydration, which could save most of the more than 4 million young children who now die each year from diarrhoeal dehydration--the single biggest killer of children.

* Breast-feeding, which can ensure that infants have the best possible food and a considerable degree of immunity from common infections during the first six months of life.

* A full $5 course of immunization, which can protect a child against measles, diphtheria, whooping cough, tetanus, tuberculosis, and polio. At present, these diseases kill an estimated 5 million young children a year, leave 5 million more mentally or physically disabled, and are a major cause of child malnutrition.

* Growth monitoring, which could help mothers to prevent most child malnutrition before it begins. With the help of a 10-cent growth chart, and basic advice on weaning, most mothers could maintain their child's healthy growth, even within limited resources.

This year, it is possible to begin reporting on the progress of these strategies.

Oral rehydration therapy 

Oral rehydration therapy (ORT) is the most dramatic of the low-cost methods for protecting the lives and health of children in low-income communities. In the past year, an estimated half a million lives have been saved through ORT, and 38 nations have begun large-scale production of the oral rehydration salts.

On average, a child living in a poor community in the developing world will suffer an attack of diarrhoeal infection somewhere between two and six times per year. Every episode of diarrhoea lowers the child's nutritional level, and every episode carries with it the risk of death from dehydration. In a country like Bangladesh, for example, diarrhoeal dehydration kills almost 10 per cent of all children.

The cause of diarrhoea is poverty-poor water supply, poor sanitation, poor health education and poor housing. ORT will not change that poverty. But it will provide a remarkable degree of protection from one of poverty's worst effects.

In almost all cases, dehydration can be kept at bay by a parent who knows how to manage an episode of diarrhoea. If the parent knows that feeding should continue, that an oral rehydration solution should be given to the child from the beginning of illness, and that enough should be given to replace the fluids lost during the illness itself, and that help should be sought if the diarrhoea persists or if dehydration sets in, then the lives of several million young children a year could now be saved. At the same time, the use of oral rehydration salts can mitigate the impact of the illness on the child's growth.

But whatever the potential of the technique itself, the greatest break- through remains to be made: the knowledge of how and when to use oral rehydration therapy must be put at the disposal of millions of parents the world over. At the end of 1984, less than 15 per cent of the world's families were using ORT.

However, people do not suddenly begin to use ORT just because the facts about it are made available, any more than people suddenly stop smoking, or change their eating habits just because new facts become known. Of the mothers who now know about ORT in Honduras or the Gambia, for example, "only" about half are actually using the therapy when their children have an attack of diarrhoea. But as more and more mothers are seen to use ORT successfully, more and more mothers will be encouraged to try it--a process which can be accelerated by using all possible channels of communication and support. Home visits and radio campaigns, voluntary action and government backing, are likely to act synergistically so that the impact of the campaign as a whole is considerably greater than the sum of its parts.

Breast-feeding

Almost unnoticed, many nations are also now moving to preserve another vital element of child protection--breast-feeding.

Breast-feeding is a natural "safety net" against the worst effects of poverty. If the child survives the first month of life (the most dangerous period of childhood), then for the next four months or so, exclusive breast-feedings go a long way towards cancelling out the health difference between being born into poverty and being born into affluence. Even under the poorest roof, a child who is breast-fed in this period is likely to be as healthy and to grow as well as a baby born into a European or North American home.

In recent years, however, there have been signs that this strand of child protection is beginning to fray. In many cities of the developing world, the incidence and duration of breast-feeding has begun to fall precipitously.

Encouraged by hospitals, doctors, advertisements of infant-formula manufacturers, the demands of wage employment outside the home, and their own belief that bottle-feeding is more sophisticated, many mothers either have not begun to breast-feed at all or have not persisted beyond the first few weeks. But equally often, mothers in poor communities are unable to afford sufficient quantities of infant formula, unable to read the instructions on the back of the container, unable to obtain clean water, or sterilize bottles and teats, or to keep the solution cool. They are therefore trapped into spending money they cannot afford on feeding their children with over-diluted milk powder from unclean milk bottles. The result can be a doubling or trebling of malnutrition, infection, and infant deaths.

Stopping the irresponsible advertising of breast-milk substitutes is not enough. In the present climate of conflicting social pressures and growing uncertainties, breast-feeding also needs to be promoted. Knowledge about the protection offered by breast-feeding--and the dangers threatened by bottle-feeding--should be made available to all mothers who may be in doubt--and to all those who are in a position to influence the mother's decision.

But like the campaign to promote oral rehydration therapy, the campaign to protect breast-feeding must also recognize that it demands a great deal of the mother's time, patience, and freedom of movement and is a "nutritional stress" on the mother herself.

Action to encourage breast-feeding needs to be supported by a wider range of measures, as many countries have recognized. Working mothers, in particular, require special arrangements if they are to be able to breast-feed their babies--such as guaranteed, adequate and fully paid maternity leave, arrangements for home help, day-care centres near the work-place, and nursing breaks at work. Viet Nam, for instance, now allows an hour of break for nursing mothers during the working day until the baby is a year old, and Lesotho recently introduced legislation providing for 90 days maternity leave and nursing facilities at or near the workplace.

Overcoming those problems is not a task for women alone. An increase in a woman's share of family food, and a lightening of her work-load during periods of pregnancy and breastfeeding, are the two most obvious ways by which the community as a whole--and especially its men--can help to extend the protection of breast-feeding to all children.

Immunization

For a total cost of approximately $5, a child can now be immunized against six of the most common and dangerous diseases of childhood--measles, tetanus, pertussis (whooping cough), diphtheria, poliomyelitis and tuberculosis. But in 1984, less than 20 per cent of the developing world's children were protected against all or most of those infections.

A great deal of recent research has concentrated on technologies to make immunization more widely available, including more heat-stable vaccines, better and cheaper methods of sterilizing equipment, improvements in cold-chain technology, and the development of colour-change indicators to monitor the potency of vaccines.

But the gap between immunization's potential and performance will never be bridged by technology alone. Present immunization rates could be doubled, and in many cases trebled, if parents took advantage of existing immunization services and if those who brought their child for the first immunization were also to turn up for the second and third injections. In 81 immunization campaigns in Africa and Asia surveyed by the World Health Organization between 1979 and 1983, the average drop-out rate between the first and third "shots" of diphtheria vaccine was almost 40 per cent.

Empowering parents with information about what immunization offers--a reduction of at least a quarter in the risk of child death--can increase the distance which parents are prepared to travel. In addition, making immunization available at times and places more convenient to working people can reduce the distance which parents need to travel. Both bring immunization nearer.

As Donald Henderson, now Dean of the Johns Hopkins School of Hygiene and Public Health and formerly director of WHO's successful smallpox campaign, has explained:

"When immunization . . . is brought to the residents at a time of day when villagers are not in the fields or at the market, acceptance by 90 percent or more is common. Comparable results are obtained if immunization is offered at convenient assembly points which are not too distant provided that the program is well organized and promoted . . . Remarkably high levels of acceptance have been achieved when educational and promotional methods have been imaginative."

Growth monitoring

Malnutrition is an age-old scourge. But in recent years, there has been a quiet revolution in our understanding about what causes child malnutrition--and what can be done to prevent it:

* Most malnutrition is invisible and most parents of malnourished children do not know that there is anything wrong.

* Most malnourished children live in homes where there is no absolute shortage of sufficient food to provide an adequate diet for a small child.

* Most malnutrition is caused not so much by lack of food as by repeated infections which burn up calories, depress the appetite, drain away nutrients in vomiting or diarrhoea, and often induce mothers to stop feeding while the illness lasts.

The two common failings of present efforts to combat child malnutrition are that they concentrate on the treatment of malnutrition rather than its prevention, and that they do not sufficiently involve the mother in learning how to pr event malnutrition from recurring.

If the early signs of faltering growth could be made visible to the mother, and if at the same time she could be made aware of the special food needs of the very young child, then it would be possible to prevent perhaps half or more of all child malnutrition in the developing world, even within existing family resources.

The low-cost technology for making that malnutrition visible already exists in the form of growth charts which are now coming into use in over 80 countries. By weighing the child each month and entering the result on the chart, the first signs of poor growth are made visible to both mothers and health workers. If a mother can see her child's progress beginning to falter, she will take action to put the child back on course. Sometimes, she need no further information. More often she will need, and seek, advice on how to maintain the child's normal healthy growth.

That advice might include:

* Continue breast-feeding until the child is at least one year old.

* At the age of four or five months, begin giving the child other foods--whatever is in the family pot, plus a little oil and some skinned and mashed vegetables.

* Children have small stomachs, so feed a child often, even if only a small amount.

* persist in feeding during illness or diarrhoea, even though the child has no appetite.

* The three to five days after an illness are a special time for catching up on lost growth; frequent feeding in those few days will help towards a complete recovery.

* Wash hands often, and especially after defecating and before preparing food. Keep food clean.

Marketing survival

If the child survival revolution is to be a revolution for the majority, it must depend more on ordinary families than on medical institutions. The mother needs to be seen as the centre of child health care. It is she who is the highest-level health worker--not in training or in qualifications, but in time and love, in the special knowledge of her own children, in the breadth of "integrated services" she provides, and in the permanent presence she brings to her child's life.

Empowering mothers with present knowledge and techniques of child protection is therefore the key to unlocking the present potential for a revolution in child health. But the responsibility for turning that key rests with the whole of society. For the mother cannot act alone, should not bear the responsibility alone, and cannot be empowered by information alone.

Recent research in the developing world has highlighted three kinds of support of women which are of such potential significance for their own and their children's health that they must also now be counted among the breakthroughs in knowledge which could change the ratio between a country's health and wealth. Those changes are:

Female education: Even within low-income communities, a child born to a mother with no education has been shown to be twice as likely to die in infancy as a child born to a mother with even four years of schooling.

Family spacing: Infant and child deaths have been found to be, on average, twice as high when the interval between birth is less than two years.

Food supplements: A handful of extra food each day for at-risk pregnant women has been shown to reduce the risk of low birth-weight--a risk which carries with it a two or three times greater likelihood of death in infancy.

Inasmuch as the prospects for a revolution in child survival depend on the communication of practicable information to millions of parents, the modern mass media are clearly a powerful resource for helping to bring that revolution about.

In the developing world, the new capacity for mass communications has also opened up a potential for social marketing campaigns. In the last few years, much has been learned about the possibilities--and limitations--of social marketing as a means of bringing about improvements in the field of health and nutrition.

But it is clear that people's lives and behaviour cannot be transformed simply by waving the magic wans of social marketing. Mass media messages about the need to boil water or to breast-feed or to feed a child more frequently cannot solve the problems of firewood shortage or maternity leave or give a mother more energy or more hours in the day.

It is also important to recognize the differences as well as the similarities between commercial marketing and social marketing. Most commercial advertising aims to promote brandname consciousness in a competitive market and to associate product with moods and emotions. But because social marketing campaigns usually seek a more important change in behaviour and attitudes than a change in loyalties to a particular brand name, mass media messages in themselves are usually not enough. In the promotion of a more complex process such as ORT, for example, mass media campaigns can be an important complement to, but not an adequate substitute for, practical face-to-face demonstrations by health workers or trained volunteers.

Health service for all

The community-based health worker, even with only a few months of training and a minimum of equipment, can be the mother's most important source of information and practical support. Such health workers are often volunteer village women.

Most mothers want and need a one-to-one demonstration on how to make up oral rehydration salts and when to use them. Similarly, most mothers need someone to turn to for reminders about immunization schedules; for advice and support on the question of birth spacing; for reassurance about breast-feeding (and for help with problems which may arise; for help with weighing and growth monitoring; for advice on how and when to begin weaning; for checking on tetanus immunization and weight gain during pregnancy; and for help in getting to more qualified services should that be necessary.

Out of 122 nations recently surveyed by the World Health Organization, primary health care is now official policy in 78. India has trained 340,000 health guides and volunteers, for example, and Thailand has trained 384,000 health communications. In Tanzania, almost every village now has one health post attended by a trained person; in Botswanan, 80 per cent of the villages have village health committees; in the Republic of Korea, 2,000 community health practitioners will be available to two-thirds of the population by the end of 1985. In Burma, 13,000 community-based health workers are being trained in five years.

The World Health Organization estimates that approximately three-quarters of all health spending in the developing world is being used to provide relatively expensive medical care for a relatively small minority in the towns and cities. Over half of the national health budget in Senegal or the Philippines or Tanzania, for example is spent on urban hospitals. In the Congo, only 1.5 per cent of the Ministry of Health's annual budget is being spent on preventive medicine.

Often, a relatively small shift in this pattern of spending could release the resources to train large numbers of community health workers. In Latin America, for example, the medical schools are scheduled to produce an additional 200,000 fully qualified doctors by 200,000 fully qualified doctors by 1990. For the same cost, it would be possible to train a few less doctors--say a total of 150,000--plus one million health care workers to live in poor communities and help make available the knowledge and the techniques for drastically reducing child illness and death among the majority of the population.

Traditional birth attendants

The fact that two-thirds of the developing world's poor do not have access to modern medical services does not mean, however, that they have nowhere and no none to turn to when they need help. For the great majority of mothers in the developing world, the local midwife, or traditional birth attendant is the most important source of support in pregnancy, childbirth, and early child care.

Experience has shown that most traditional birth attendants welcome training in new techniques when it is offered. Modern health services can provide that training. But in the modern health establishment, there has been a pronounced tendency to look down on the traditional birth attendants as ignorant and superstitious practitioners of unscientific and unhygienic methods for dealing with pregnancy and childbirth. Commonly, they have been accused of performing dangerous abdominal massages during pregnancy, or of advising mothers to discard the colostrum which precedes the breat-milk (and which contains valuable immunological properties), or of failing to cut and dress the umbilical cord hygienically, or of advising mothers to eat less in pregnancy, or of not knowing what to do in the 10 per cent to 20 per cent of births when complications arise. In some cases, these accusations are well-founded. Some traditional birth attendants do promote and practise many dangerous and ill-founded ideas during pregnancy, delivery and infancy.

Clearly, modern health practitioners have much to teach the traditional village midwife. But they may also have much to learn. For it would be a mistake to assume that the majority of village women go to traditional birth attendants only because they are there. In many countries, the poor prefer traditional birth attendants, even when more modern health care is available.

To many women, sharing something as intimate and personal as childbirth with somebody who is a complete stranger and whose interest in the mother seems to be confined to the clinical, is an unaccustomed notion. Some traditional midwives concern themselves not only with all aspects of pregnancy and childbirth, but also with child care up to and beyond the first month of life and with the more rounded needs of the mother herself--with her emotional life, her family relations, and with the necessary rituals, prayers, and social obligations of childbirth itself. In many cases, village midwives also clean the house and wash the bed-linen after the birth. Some take on the cooking and household chores to give the mother time to rest and be with her baby. Some may even act as god-parent.

Because of recent breakthroughs in knowledge, even a few weeks' training in low-cost methods of child protection can enable a traditional midwife to drastically reduce the incidence of child deaths and child illness in poor communities. And training those to whom the majority of the poor already turn for help in the task of bearing and caring for children is therefore one of the most cost-effective of all methods for making new knowledge available to the vast majority of parents in the poor world.

Oral rehydration: story of a breakthrough

It is estimated that some 4 million children die every year from the dehydration that can result from the condition in which fluid losses can quickly drain away 10 per cent of the child's body weight. Previously, the only cure was sophisticated intravenous therapy. The oral rehydration technique involves a small container of salts made up to an aproved formula. In the past year UNICEF has supplied 78 countries with some 65 million packages.

Water, salt and sugar seems a simple formula. But the scientific development of oral rehydration therapy (ORT), the treatment that can prevent millions of deaths from diarrhoeal dehydration, was anything but straight-forward. Naomi Rock Novak's history of ORT, soon to be published by UNICEF, details the work involved in discovering precisely how diarrhoea causes fluid and salt loss, and how to replace the losses.

Interest in rehydration was sparked by cholera. Starting in 1818, lethal epidemics swept across four continents. But it took over 100 years to prove the valye of intravenous rehydration:

* 1832: Thomas Latta, an Irish physician, gave a saline solution by injection to 15 dying cholera victims. He stopped the treatment too soon at first and only the last five survived. The Lancet, leading British medical journal, praised his work, but for 80 years the medical profession balked at a remedy it considered questionable.

* 1908-1915: Leonard Rogers, an English pathologist working in Calcutta, gradually reduced cholera death rates from 60 per cent to 20 per cent using intravenous saline solution. Bicarbonate was added in 1915. Even so, the high salt content of "Rogers' solution" often killed.

* 1949: Daniel Darrow and Edward Pratt at Yale University added potassium.

* 1958: Robert Phillips and Raymond Watten, United States Navy researchers in Bangkok, set the correct balance for intravenous rehydration. Essentially the same solution is used today.

Oral rehydration took longer to develop:

* 1830: W. Stevens, in the West Indies and London gave his diarrhoeic patients water and salts to drink. But the conviction that cholera destroyed the gut wall--which would prevent rehydration by mouth--persisted for another century.

* Late 1940s: R.B. Fisher and D.S. Parsons, two Oxford University researchers who were not studing cholera, made a crucial discovery: when glucose was absorbed through the walls of the small intestine, it carried salts and water with it.

* 1968: Building on years of international research, Michael Field of Harvard and William Greenough at John Hopkins University proved how cholera provoked fluid loss and confirmed the value of glucose transport.

Those pathology studies provided the scientific underpinnings of ORT. Concurrent experiments supplied the empirical evidence:

$ 1962: Robert Phillips, now in Manila, successfully mixed salts and glucose to maintain hydration orally in cholera patients. But after five patients died in one trial from sodium overload, Phillips, distressed, abandoned his experiments.

* 1966-1968: Appointed director of the Cholera Research Laboratory in East Pakistan (now Bangladesh), Phillips returned to ORT studies. At the Laboratory, scientists developed a formula which passed its first large-scale test during a local cholera epidemic. A laboratory team reported that ORT reduced the need for intravenous treatment by 80 per cent; moderately dehydrated patients could recover on ORT alone.

* 1971: During the civil war in East Pakistan, cholera raged in the refugee camps of neighbouring India. Nearly one in three victims died and intravenous supplies ran short. A team from the Johns Hopkins research centre in Calcutta, led by Indian scientist Dilip Mahalanabis, treated 3,700 patients with ORT alone. Only 3.6 per cent died.

The story of oral rehydration does not end there. Many scientists helped to develop ORT and are continiuing work to perfect it at the Cholera Research Laboratory--now the International Centre for Diarrhoeal Disease Research Laboratory--now the International Centre for Diarrhoeal Disease Research, Bangladesh--and elsewhere. The greatest task of all still remains, however: to make ORT known and available to those who most need it.

Diabilities: the preventable burden

One in 10 of the world's people--some 460 million--suffers from mental or physical disability. Four out of five live in developing countries. And one third are children under 15. The low-cost child survival techniques discussed in the State of the World's Children report would also reduce this unacceptable toll:

* Expanded immunization would prevent polio, which cripples half a million children every year. In some developing countries between two and nine of every 1,000 schoolchildren are lame.

* Measles, a major killer, can also lead to malnutrition and disability. In about 30 per cent of cases, the children who survive the disease fall prey to its complications: conjunctivitis, which can cause blindness; middle-ear infection and subsequent deafness; encephalitis, which can cause permanent brain damage; and severe malnutrition resulting from loss of appetie and diarrhoea.

* Tuberculosis can eventually lead to meningitis, spinal deformity, swollen joints and the chronic incapacity of pulmonary tuberculosis.

Not all disabilities are as obvious as deafness or lameness. Many millions of children fall victim to the invisible disability of poor mental and physical development, caused by the frequency of illnesses and assaults on their growth during those first two or three years which are most vital for the evolution of brain and body. Once that growth opportunity has passed, it can never be caught up again. So poor growth in childhood is the most widespread--though the least noticeable--form of disability in the world today. All the main techniques of the child survival revolution--oral rehydration therapy, breast-feeding and improved weaning, immunization, and growth monitoring--save lives by protecting growth. They would therefore also save many millions of children from physical and mental handicap.

Another key element in the child survival revolution is preventing low birth-weight, which carries with it such high risk of death and poor growth in infancy. Of the 21 million low birth-weight babies born every year, over 19 million are born in developing countries, where two out of three pregnant women are anaemic and many are malnourished. Even a handful of extra rice each day in the last three months of pregnancy can go a long way towards preventing low birth-weight. Beteer diet or inexpensive iron supplements can ward off anaemia. Once again, such a strategy could prevent disabilities as well as save lives: children born underweight are four to six times more vulnerable to mental or physical handicap than babies of normal birth-weight.

Other disabilities, too, can be prevented at low cost, although supplying the remedies can prove complex. Iodine deficiency, which in some mountainous parts of the world sets entire populations at risk of stunted growth, daf-mutism and mental retardation, can be prevented for a few cents by adding iodine to salt and other common foods or by injections of iodated oil. Lack of vitamin A blinds an estimated 500,000 children every year and can be remedied by vitamin supplements costing 20 cents or less a year per person, or by teaching mothers to feed their children green vegetables.

When disability has not been prevented, children who develop impairments need early diagnosis and rehabilitation to help them realize their potential. Yet 98 per cent of the developing world's disabled have no access to trained help.

One solution is community-based rehabilitation programmes, which call on the resources of village health workers and villagers themselves. When community health workers in Toluca, Mexico had been specially trained, they substantially improved the living conditions of 70 per cent of the disabled in their charge; only 10 per cent needed specialized rehabilitation services. Such programmes cost only $9 a year for each disabled person.

The many problems which beset the opportunity for a revolution in child health, two are so profound and pervasive as to demand acknowledgement even in a report which traditionally emphasizes opportunities rather than constraints.

First is the fact that many mothers in poor communities are already so overwhelmed by work, and so unsupported by male-dominated societies, that they have little time and energy left to put into action the child protection strategies which might now be placed at their disposal.

Second is the problem that slow progress towards basic services--and especially clean water and safe sanitation--is still acting as a brake on almost all other child survival strategies.

Women's Work

Longer breast-feeding consumes time and energy; oral rehydration therapy demands time and patience to mix up a fresh solution each morning and administer it slowly several times a day to a sick child; preventing malnutrition will mean taking a child to be weighed each month and spending more time in the preparation of the four to five feeds a day which are necessary for safer weaning; and making sure a child is immunized means repeated trips to health clinics or vaccination posts.

Yet many of the women of the poorest communities in the developing world are already working 12 to 16 hours a day. Often spending many more hours in the fields than men, women are responsible for at least 50 per cent of family food production in the developing world. Once the harvest is in, it is also the woman's job to do all the pounding, winnowing, grinding, boiling, straining, drying and storing of the family's staple foods. On top of that, women are normally responsible for collecting firewood and drawing water, gathering fodder and looking after animals, tending kitchen gardens and marketing any surplus, cooking and washing up after meals, cleaning and washing clothes, sewing and weaving, maintaining social obligations and attending to the sick and the elderly--and all of this on top of the tasks of bearing and caring for children.

To the long hours of physical toil in fields and homes must be added the physical burdens and nutritional stresses of repeated pregnancy and of breast-feeding. At the age of 30, a woman has often spent 80 per cent of her adult life in the stressful process of reproduction and breast-feeding. The result is that too many women are worn out by work and by child-bearing. Every year, half a million mothers die from causes related to maternity. And for every mother who dies, many struggle on in a state euphemistically know as "maternal depletion".

If mothers in poor communities are to put into practice the strategies now available for protecting the lives and the growth of their children, they will need practical support from their men, their communities, their leaders, and their governments. They will need, for example, technologies which relieve them of the hours a day spent collecting wood for an inefficient open stove, or the hours a day pounding grain with a pestle and grinding it with a stone, or the miles and hours a day spent carrying water. They will also need a fairer division, within the family, of labour and of food.

In short, progress in women's rights is possibly the most important of all advances for improving the lives of women themselves and for supporting mothers in the task of using the new techniques to bring about a revolution in child survival.

Water and sanitation

It has long been known that three-quarters of all the illness in the developing world is associated, in one way or another, with inadequate water supply and sanitation. And until relatively recently, it has been assumed that providing good water and sanitation facilities would therefore wash away a similar proportion of the poor world's health problems.

In practice, clean water by itself has been shown to have disappointingly little effect on the health of low-income communities. By the middle of the last century, the city of London had put piped water into almost every home. But it was not until early this century that the incidence of diarrhoeal infection began its steep decline. It was the educated use of water to improve hygiene which finally brought about the decline--over half a century after the water supply itself was installed.

With clean water and sanitation, a community can drastically reduce the incidence of parasitic diseases which sap the energy of hundreds of millions of adults and affect the nutritional health of large numbers of children. It can also drastically reduce the incidence of diarrhoeal infection.

With clean water and sanitation, a community can also improve its level of nutrition--by irrigation of crops and kitchen gardens, by reducing the infections and parasitic loads which "waste" the food that is eaten, and by preventing the contamination of food itself. A clean water supply can also reduce the daily burden of fetching and carrying water.

If safe water and sanitation can offer so much for so little, why have actual large-scale water projects proved to be so disappointing in their effect on community health? Once again, the discrepancy between potential and performance is a measure of the difference between availability and use. Even when piped water is available it will not reduce illness unless a community uses it for frequent washing of hands and bodies and for the cleaning of utensils and cooking surfaces. And even with improved sanitation, illness will not decline unless latrines are kept clean and used by everybody--including the children. It is widely believed, in developed as well as developing countries, that it is not so important for children to use latrines or to wash their hands afterwards. But the fact is that children are the main sources as well as the main sufferers of diarrhoeal infections.

It is not water or sanitation which washes away illness, it is people's informed use of those facilities which can improve community health and magnify the effect of all other attempts to protect the lives and the growth of children.

Ironically, the potential for significantly improving the "state of the world's children" arises at a time when the economic position of many of the world's poorest families is becoming worse.

A special study published by UNICEF earlier this year on the impact of the world recession on the world's children uncovered some grim facts about falling family incomes and cut-backs in government expenditure on social services. The study also showed that recession strikes progressively harder at those with the least to fall back on: the developing countries, the poorest population groups in those countries, and finally the most vulnerable group of all--the poorest mothers and their young children.

Since the study was commissioned the recession has begun to lift in the industrialized countries--modestly in Europe, more strongly in the North American economy. The developing countries, too, have begun to show signs of recovery; their GNP per capita, which fell by 2.5 per cent in 1983, was due to rise by 0.5 per cent or 1 per cent in 1984. But so far the improvement is concentrated in the relatively well-off countries of East and South-East Asia. India, for instance, has regained some of its momentum, largely because of imrpoved agricultural production. In the Republic of Korea, GNP has grown rapidly over the last two years and infant mortality has fallen to the lowest level ever recorded.

But elsewhere prospects are bleak. There is no sign of recovery in Africa, the poorest of all continents, with Governments beset by low earnings and high debts and with an estimated 150 million people at risk from the effects of three years of drought. In Nigeria, for example, government revenue has dropped by more than half over the past two years. The numbers of severely malnourished children are rising and hunger has been a daily theme in newspaper editorials during 1984.

In Latin America, per capita incomes fell in 17 out of 19 countries during 1983, and GNP in the region as a whole dropped by over 5 per cent. Crippling debt repayments have forced massive retrenchment, with social welfare programmes the first to suffer, and prices increased sharply.

Those economic stresses have taken their toll on children:

* Infant mortality is rising sharply in the poorer states of Brazil; in some parts of the north-east, one in five children dies before reaching the age of one year.

* In Bolivia, food prices rose tenfold in the year ending June 1984, and drought reduced the 1984 harvest to an estimated 60 per cent of normal. Infant mortality rates have remained stable, thanks to major immunization and oral rehydration campaigns, but child malnutrition has increased steeply in the drought areas.

* In Peru, GNP per capita dropped by more than 14 per cent in 1983 and continued to fall in 1984. The Food and Agriculture Organization judges that 63 per cent of households do not earn enough to buy even an adequate diet. Outbreaks of tuberculosis, malaria and other infectious diseases are increasingly common.

* In Sri Lanka, inflation and cut-backs in government spending have eroded the food-stamp programme and led to an increase in malnutrition among the children of the poor.

At the start of 1984 the UNICEF study predicted that the worst was yet to come. The prediction holds for those countries which have been unable to improve their economic performance--or to shield their children from the worst consequences of recession.

In a poor community of the developing world, a baby who is bottle-fed is two or three times more likely to die in infancy than a baby who is breast-fed. The steep decline of breast-feeding in the cities of the developing world has therefore become a major cause for concern.

One of the most visible forces behind the rise of bottle-feeding has been the advertising of infant formulas by the commercial baby-food companies. In May 1981, after a 10-year campaign by health professionals, non-governmental organizations and international agencies, the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes.

The aim of the Code is "the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution."

By mid-1984, three years after the Code's adoption, the World Health Organization reported that the Code had been translated into 17 languages and that 130 countries had taken some form of action on it. More than 18 industrialized and developing countries have enacted national codes or adapted existing legislation to include the Code's provisions; and at least 34 countries are currently drafting legislation.

Some 33 Governments have banned the advertising of breast-milk substitutes to the public, and 17 have actively used the mass media to promote breast-feeding. In the Philippines, for example, the Ministry of Health is leading a national breast-feeding campaign which uses radio and television sopts, posters, and manuals and handbooks for health personnel; bottle-feeding publicity is barred from hospitals and health centres. In Brazil, television networks have donated more than $1 million a year in broadcasting time to promote breast-feeding, with leading actresses and celebrities giving their time free of charge.

Most infant-formula manufacturers have now accepted the Code's main provisions and have agreed to abide by them when selling their products in developing countries. Nestle, which controls 50 per cent of the infant-formula market, has agreed to comply with the Code's basic provisions and the international boycott of Nestle products has now been lifted.

But some manufacturers still regard the Code as unjustified restriction on the marketing of their products, and infringements consequently persist. In one three-week period during 1984, the International Baby Food Action Network reported more than 100 violations of the Code by 22 companies in 10 different countries.

Many organizations, national and international, have joined forces, to publicize the dangers of milk substitutes. National coalitions to protect breast-feeding have been established in Costa Rica, India, Kenya, Malaysia, Peru, the Philippines, and other developing countries. All these organizations are continuing to play a vital role in monitoring the marketing of infant formula.