--- Acknowledgements --- To Rebecca Robertson, for showing me that there may be hope yet.Cynthia LewisANTH 41013 March 2013 Child Mortality: The Death of Generations in Uganda Screaming, its arms waving feebly, the newborn kicks his way free of the damp andthe dark to draw his first breath through undersized lungs. Sensations flood his tiny brain:sounds, scents, light streaming from the cracks in the roof. He closes his eyes to theonslaught, whimpering and vulnerable. This is only the beginning; the childs early life willbecome a constant struggle for survival as he battles the pains of an empty stomach and adeluge of sickness. He very likely may not survive to see his fifth birthday. In Uganda, one inevery thirteen babies will not survive the first year, and one in seven will not live to see theirfifth birthday (Bbaale). Increasing child mortality rates have been one of the most severeissues facing Africa over the centuries, and the health systems in place have done little torectify this growing problem. The many factors that contribute to childhood mortality inUganda need to be addressed through a change in government policy and the implementationof effective health programs. As the third world moves ever closer to a developed status, Africa lingers behind,plagued with childhood illnesses made worse through the increasing occurrence ofmalnutrition. Severe acute malnutrition is defined as a very low weight to height ratio with anarm circumference less than 110mm in children aged 6-59 months (Fishman). For reference,the standard U.S. quarter has a circumference of 78.5 mm, which makes the thought of ahuman appendage being of a similar size very disturbing indeed. The natural reaction toimages of starving children in Africa is one of disgust and denial. Much of the developedworld would like to ignore the truth of these children’s sufferings and hope that the problem
will simply go away and cease to affect the civilized world. However, this is not merely anisolated epidemic of some rampant disease, but the very treatable and preventable reality ofthe lives of nearly twenty million children worldwide under the age of five. As of 2006,16.4% of children under five in Uganda were considered critically underweight (“Uganda”).The majority of those twenty million children who suffer from severe acute malnutrition livein the countries of sub-Saharan Africa, whose governments are proving to lack the health careprograms needed to effectively treat and care for their citizens. This appalling disregard for the basic human right to due care from one’s governmenthas created a mounting crisis for the future generations of Uganda. The rate of death formalnourished children is 5-20 times higher than those who are considered well-nourished andreceive proper daily nutrition (Community-based Management). While there is a startlinglack of nationally-funded and easily-accessible health resources, there are certain measuresthat can be undertaken to ensure proper nutrition within the home. There has been a recentbid to push the manufacture of Ready-to-Use Therapeutic Foods (RUTF) that contain specificnutrients that malnourished children need in order to maintain a healthy weight. 10-12% of achilds daily energy intake should come from protein and 45-60% from lipids and fats.Protein and fat molecules make up much of the RUTF powdered formulas, and these can bemixed and sold within the rural community or bought at $3 per kilogram from governmenthealth clinics when one is within a reachable distance. 10-15 kg of this dietary supplement isgiven over a period of six to eight weeks to treat cases of near-death malnutrition(Community-based Management). For those who can’t afford them, breastfeeding isencouraged for the first six months of a newborns life, followed by a regimen of high-proteinmilk products when possible. There are a plethora of factors that both contribute to childhood mortality and help toprevent it. A study done on several villages in north-west Uganda brought to light many
factors beyond malnutrition that effect the rates of child mortality. These included obviousfactors such as poverty level and parental education, sanitation, common illnesses likediarrhea, infections, and family size. The study also analyzed less commonly-depicteddeterminants such as the interval between births and birthing order, mothers timeavailability, and knowledge and utilization of child-rearing practices. The order in whichchildren were born to a single mother could impact their expected chance of a healthy life.Children who were the third, fourth, or fifth birth had an increased survival rate than thoseborn previously or thereafter (Vella). A complimentary study done on villages in south-west Uganda uncovered moredeterminants. These included parents’ occupation, presence of a well-ordered latrine, accessto livestock, daily religious practices, and the familys socioeconomic status and purchasingpower. If a family raises livestock, the children of that family may have an enhanced dietincorporating fresh meat, eggs, milk, etc. Clean latrines minimize the likelihood of the spreadof disease, while religious practices such as ritual cleansing and washing may decrease thespread of common illness as well. A child born in a Catholic, Protestant, or Muslim home hasa probability of death 5.0, 4.2, and 3.5% respectively lower than their counterparts born toother faiths (Vella). This is largely because these three religions are often ofﬁciallyrecognized by many governments in Africa and are therefore more likely to have establishedschools, hospitals, volunteer health resources, missionary outreach programs, or charity-funded clinics. The clear organizational hierarchies of these religions would, in essence, givethe children of these faiths access to entire communities dedicated to enhancing and enrichingthe lives of their members. One factor that has a weighty impact on the health of a child is the level of educationacquired by the mother, which has been repeatedly shown to be largely influential in reducingthe rate of child mortality. This is due to the understanding that a well-educated mother is
more likely to know and utilize healthy child-rearing practices. Educated mothers often havea heightened appreciation for the best practices in childcare activities and the importance ofimmunization, providing adequate nutrition, and seeking modern health care. They also tendto have a superior awareness of childhood diseases and are more informed on how toproperly treat them. On the other hand, mothers who received little education are more likelyto work in jobs that are physically exhausting, time-consuming, and pay lower wages(Bbaale). This means the less-educated mother will typically spend less time at home withher children, is often too tired to care for them properly, will lack the superior understandingof common illnesses and their treatments, and has fewer resources and less money withwhich to purchase food and medicine. Fortunately, there are programs in place in Uganda that support the education offemales. The Ugandan government currently funds free primary and secondary education,and women are encouraged to further their education in a national effort to postpone marriageand pregnancy. The only difficulty with these efforts is that an array of factors may makeaccess to government-funded schooling difficult: cultural and circumstantial barriers, or aninsurmountable physical distance between a rural village and an established school oruniversity. For those who can take advantage of these programs, there are correlated benefitsthat have been shown to come hand in hand with the further increase of a mother’s education.Interesting results from Bbaale’s and Buyinza’s research show that the neonatal mortality ratein Uganda is 40% for mothers aged 16–20 years, 49 per cent for mothers aged 21–25, and 0%for mothers aged 36–40 years. Encouraging the education of a young woman beyondsecondary level is one way to ensure that the minimum age at which she marries and hasoffspring is around 23 years, which happens to be the average age at which an undergraduatedegree is completed in Uganda. Children borne to mothers with no education have the highestneonatal mortality rate of about 63% compared to 13% for those borne to mothers with
secondary education and only 2% borne to mothers with post-secondary education. Theattainment of post-secondary education may be a lofty goal for many Ugandan mothers, but itis inherently worth the time and effort if they intend to eventually reproduce and raise ahealthy family. While improvements in maternal education are underway, there is still an appallinglack of access to health care for most citizens in rural Ugandan villagess. It is less likely thatthere is an established health clinic within an accessible distance in rural areas (“accessible”being the operative word). The average distance to a health center is 7 miles; to a privateclinic, 9 miles; and to a hospital, 12 miles. According to Ugandan health-care author CharlesKatende, “for every 1% increase in distance to a health center, the risk of childhood mortalityincreases by 19%” (Katende). These distances may seem trivial to a modern world wheretransportation is readily available and a few kilometers is reduced to a ten minute journey inany car. To many rural Ugandans, however, the 7-mile trip to a health center may mean atwo-day trek. While there may be free or reduced-price medicines and care available atclinics and hospitals, the amount of effort expounded to reach them is often not worth theeffort or the consequences of taking the time away from work. These factors only add to thedilemma of mortality facing the country, discouraging rural families from seeking proper carefor their ailing children. In order to improve the overall access to health care, Uganda’s government needs toimplement efficient political strategies. These strategies would require investment intovarious factors to be even remotely successful. Before progress could be made, Ugandawould first need a just political leadership that is accountable to its sick and starving people(“Successful Leadership”). This accountability would help to motivate officials to attend tothe necessities of the populace, and those same officials would need to utilize sound healthpolicies that would apply universally to all citizens of Uganda without exception. There
would need to be an effective use of national financing and aid grants dedicated to buildingclinics and hospitals in remote, yet heavily-populated regions. In order to encourage a solidnational health-care system, time, energy, and money would need to be invested into a strongfoundation of trained workers and community advocates (“Successful Leadership”). Yet mostimportantly, real actions would need to be implemented that would ensure equal access for allrural peoples to the medical assistance that they require. There is an approach that the government of Uganda could potentially adopt, amethod called the Integrated Management of Childhood Illness. This form of approach isintended to ensure that national protocols for the management of severe acute malnutritionand childhood HIV and AIDS have a strong community component that complementsfacility-based activities. Such activities would include on-going interventions aimed atidentifying and treating children in rural parts of the country at all times of the year througheffective community mobilization (Community-based Management). Advocates wouldprovide training and support for community health workers to identify children with severeacute malnutrition and HIV/AIDS who need urgent treatment, hopefully reducing the chanceof their illness becoming a death-sentence. Given the tendency of overlap of multiplediseases, viruses, and malnutrition, these children--especially in the poorest rural areas-- arefighting a battle for life that they cannot win alone. This is why accessible, community-basedprograms are so essential where free or low-cost testing could be made available for bothmothers and their children. If diagnosed as HIV-positive, “they should qualify forcotrimoxazole prophylaxis [medical interventions] to prevent the risk of contractingPneumocystis pneumonia and other infections, and for antiretroviral therapy when indicated”(Guidelines). This would bring the country one step closer to providing the future of Ugandawith the basis for a healthy (or at least nominally healthier) life, and with an increased chanceof survival for which every human being has the right to strive.
Several developing countries have devised and administered efficient actions to lowerthe rate of child mortality in small, but successful ways, helping to guarantee this right totheir citizens. The following models demonstrate proven strategies that Uganda could verywell implement as prospective solutions to the ever-worsening situation of child and infantdeath. For example, in Thailand administration reforms have invested in district healthsystems to build a solid health care network for mothers and young children, employing mid-level health workers, and ensuring enough workers are on hand to serve in remote areas(Successful Leadership). Rural communities have also become involved in delivery servicesthat bring care packages--including food and medicine--to isolated families. The country alsosupports local generic drug production which reduces the cost of antiretrovirals, and 97% ofbirths in Thailand are attended by skilled professionals with no difference in cost for thepoorest families (Successful Leadership). Over the past few decades, health officials inIndonesia have trained and certified 54,000 village midwives. These midwives are equipped with small birthing units and provide outreachprograms and reproductive health services, including immunization and nutritionalinterventions. Due to the efforts of these women, over 96% of Indonesian people now haveaccess to village-based midwives (Successful Leadership). The government of Nepal hascreated a community mobilization and training program that includes women’s groups andmonthly mothers’ meetings in which participants discuss how to communicate and addresshealth problems. Aided by these informational outlets, postnatal mortality in Nepal hasdropped from 36.9 to 26.2 deaths per every 1,000 live births (Successful Leadership). Ifrelatively low-cost strategies such as these were to be implemented across the country, thereis a high probability of improvement on a massive scale. While the future of Ugandas youngest generation looks dim, progress has alreadybeen made throughout the country and there is hope for improvements both at the
government level and from volunteers on the ground. From 2006 to 2009 the organizationHealthy Child Uganda implemented an experimental study which was undertaken to measurethe possible impacts of volunteer services in rural areas where the access to health careinstitutions is limited. In the study, a total of 116 volunteers were trained in child health andbasic medical assistance, and 2 volunteers were posted in each of the 58 rural Ugandanvillages (populations less than 61,000). Within the first 18 months of the intervention, reportsrevealed a decline of 53% in child deaths under the age of five (Brenner). By the end of thestudy, results showed reductions of 10.2% in diarrhea, 5.8% in fever and malaria, and 5.1%in underweight prevalence within intervention households (Brenner). This model was shownto be inexpensive and sustainable, and if a base of community workers and volunteers couldbe trained in basic medical care, this method could potentially be upgraded to cover allUgandan communities that suffer from limited resources and high child health needs. The African organization Partnership for Maternal, Newborn, and Child Healthpublicly advocates for increased funding to children’s health care and the spreading ofknowledge and information about the drastic situation of childhood mortality. Theorganization promotes regional workshops on the role of health care professionals inachieving Millennium Development Goals 4 and 5, which aim to address maternal, child, andnewborn health (PMNCH). Developing countries around the world dedicate resources toachieving these goals, which are to reduce the mortality rate of children under five years ofage, and to reduce the mortality rate of mothers and to achieve universal access toreproductive health, respectively. The partnership contributed to the development ofInvestment Case for Health in Africa, which has emphasized the need for improved healthspending among the African Ministers of Finance (PMNCH). Due to the nature of theMinisters of Finance, PMNCH is effectively reaching out to the political head of the NationalTreasury, which is responsible for drawing up the national budget, developing economic
policies, and overseeing the financial management of government affairs. This is the exactkind of government involvement that needs to be encouraged if Uganda intends to beginimplementing efficient political strategies for an enhanced health care system with theeffective use of national funding. In order to address the mounting tide of death that is sweeping through the youngestgenerations in the country, Uganda will need to become more heavily involved in initiativesthroughout Africa that are focused on improving womens and childrens health. There is noone single action that could rectify the ongoing catastrophe of so many wasted lives. There isno one single strategy that the government of Uganda could utilize in a last-ditch attempt atmitigating the crime it has committed against its people, the crime of having set aside thedesperate needs of its citizens for decades. Instead, all of the aforementioned models shouldbe tried with every effort and resource available. Individual determinants of childhoodmortality need to be examined and ways of lowering the impact of these factors should beanalyzed with all due haste. While there is national progress being made, the fruits of theselabors have yet to reach much of the county’s rural population which makes up 87% of thenation’s people (“Uganda”). Health clinics have been established, but they are too far fromaccess to really make a difference. The country will soon fall behind the rest of thedeveloping world if it cannot rise to meet the increasing medical demands of the populace,having as little as 0.117 physicians for every 1,000 citizens (“Uganda”). In a world of suchadvancement in health technology, with all the miracles that science can provide, there is noexcuse for allowing the death of innocents to continue. Likewise, there is no viable reasonwhy the country cannot correct this crisis today so as to make a brighter future for Uganda’schildren tomorrow. There may be hope yet.
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