The growing pains of South Asia’s children

Under-5 mortality rate

Seven Million South Asian r children under the age of five died in 1990. In 2000 the figure had declined to about 3 million. However, the overall improvement in the statistical aggregate for South Asia conceals wide geographical disparities, with the gains made being lagely confined to some areas. The trends suggest that the gap between countries has narrowed considerably over the last 40 years. As the graph indicates, Afghanistan has shown no significant progress, which is perhaps inevitable in a country that has seen sustained civil and military conflict for the last 20 years. Sri Lanka on the other hand has posted very encouraging results.

Sandwiched between the two, the other South Asian countries occupy a narrow band, registering on average between 90 and 130 under-5 deaths per 1000 live births. But the average, like the aggregate, is deceptive. Central, western and south-western Pakistan and parts of central India account for the high intra-country variations in the magnitude of incidence. Mortality figures here are at par with the levels in Afghanistan, where mortality exceeds 130 children for every 1000 live births. The regions with high under-5 mortality also have high fertility rates. Women in these areas tend to bear, on average, more than four children per head, going as high as six children in some areas. This geographical coincidence of high mortality and high fertility has serious policy implications. Institutional intervention in these areas must target both mortality and fertility simultaneously if adverse demographic consequences are to be avoided.

Variations in the incidence of under-5 mortality show clear correlations with other more specific criteria as is evident from the graph representing the relationship between mother's education and children's mortality. The gap between mortality among children with illiterate mothers and mothers with secondary education is too wide to be overlooked. Across the board, increased emphasis on formal education, up to at least the school-leaving level, is a necessary condition for diminishing the rate of child mortality. Likewise, income differentials play a role in child mortality. As indicated by the graph, the two poorest segments far outstrip the two richest segments.

SAARC governments had, in the 1990s, adopted resolutions in Colombo and Rawalpindi, specifying goals relating to child development. Among others, they had committed to reducing under- 5 mortality by a third or 70 per 1000 live births, whichever is lower. It is true that South Asia as a whole has achieved significant reduction in child mortality rates. But in most countries the bulk of the reduction was achieved before the resolutions were adopted. Progress has tended to be slow from the 1990s and on current trends the SAARC goal for the year 2000 will not be achieved till 2025.

Nutrition

For the many children who die before their time, death ends the agonies that life only mulitplies. To cite just one instance, 300 million people, or 40 per cent of the world's undernourished population, live in South Asia. This is an indication of the extent of food insecurity in the region. While extremely high levels of food insecurity are confined to pockets in Bangladesh, Nepal and India, the bulk of the population, spread over a wide geographical belt covering Pakistan, northern, central, eastern and peninsular India, middle and lower Nepal and Bangladesh, lives in conditions of moderate to high food insecurity.

Under such circumstances, an inordinately large number of children suffer from different forms of malnutrition. There are more malnourished children in South Asia than in any other region.

One index of sustained malnutrition is stunting. About 80 million South Asian children under the age of five suffer from moderate to severe stunting, that is, they are shorter than they should be for their age. This is just a little under half the total number of under-five children in the region. While the trend-graph suggests that there has been some reduction in the overall malnutrition figures, the improvement has been geographically uneven. Bangladesh, Nepal and Sri Lanka have made impressive progress, but in Afghanistan, Maldives and Pakistan the figures for stunting have actually increased in recent years. In India, the regions with high prevalence of stunting also have the highest under-5 mortality figures, and it is likely that a large number of stunted children eventually die before they reach the age of five.

Malnutrition is not confined to childhood and for many, especially girls, it is a lifelong condition. One index of this is low birth weight among newborns. Barring a large stretch in Sri Lanka, parts of southern India and north-eastern India and isolated pockets in western and northern India and parts of Nepal, in much of South Asia, between one third to two third of all babies weigh less than 2500 grams at birth. This is a sign of sustained maternal malnutrition.

When the mother does not have sufficient nutrition it is unlikely that the child will receive adequate nutrition. Nutritional deficiencies during pregnancy can have adverse consequences on the child even before it is born. Iron deficiency, which results in anaemia, is one such. Anaemia in children has to be controlled and reversed in the first three years if irreversible brain damage is to be prevented.

Iodine and Vitamin A deficiencies are among the major nutritional maladies endemic to South Asia. Iodine deficiency is the main cause of preventable mental retardation. Children born to iodine-deficient mothers face a greater risk of dying before they are one year old. Iodine deficiency can be rectified through the consumption of iodised salt. While the last decade has seen considerable improvement in the number of households consuming iodised salt, there are large contiguous stretches in southern and northern India where less than half the households consume iodine through salt. The situation in Pakistan is particularly grim, with iodised salt being used by less than 25 per cent of the households.

Vitamin A deficiency affects about 100 million children worldwide and is the leading cause of blindness in developing countries. This deficiency even mild form can seriously undermine the immune system and reduce resistance to the diseases that account for a large number of child deaths. Children with Vitamin A deficiency face a 25 per cent higher risk of dying from childhood illnesses. Vitamin A supplementation through capsules is the usual mode of dealing with this deficiency. Barring Bhutan, Nepal and Pakistan the progress in administering Vitamin A supplementation has been tardy, particularly in India. In some areas there has been a dramatic increase, but largely because Vitamin supplementation was included in the polio immunisation campaign, which has been one of the major success stories of South Asia.

Immunisation

DURING THE late-1980s immunisation coverage in South Asia saw a dramatic increase. In the period thereafter some of these positive trends have been maintained. Despite these acheivements, four countries of the region–Afghanistan, Bangladesh, India and Pakistan– are among the 10 countries that remain a global priority for immunisation. Besides, the progress registered in the region has been uneven, both geographically and by disease-type. In large parts of northern India there has been little improvement in the extent of routine immunisation coverage. Measles immunisation in some of these areas is even lower than in Afghanistan.

The greatest success in eradication has been registered in the case of polio, with the vaccine being administered on well publicised National Immunisation Days. But the success of the campaign notwithstanding, most of the cases of polio reported today come from South Asia.

There is also a disturbing aspect to the relative success of the polio eradication programme. Its success has been accompanied by either stagnation or decline in immunisation against other diseases. It has been suggested that the campaign mode in which polio immunisation was carried out has distracted attention from other vaccine-preventable diseases. It is a moot point whether toning down the polio campaign will help revive the momentum of immunisation against other diseases.

The World Summit for Children had called for polio eradication, neonatal tetanus elimination, measles mortality reduction by 90 per cent and general immunisation coverage of 90 per cent. Barring polio eradication, South Asia is far away from these goals. Diptheria, whooping cough, tuberculosis and hepatitis B are the other vaccine-preventable diseases that continue to afflict children in South Asia.

One of the primary causes of poor immunisation results is the la,-k of access to vaccines. Hepatitis B is a case in point. A vaccine for it has been available since 1982, yet by the year 2000 only 50 per cent of newborns in developing countries were immunised against the disease.

If immunisation goals are to be realised, delivery mechanisms will have to strengthened. And, as the data on measles immunisation suggests, the gap in access between the richest strata and the poorest will have to be narrowed.

Safe Drinking Water

By the year 2000 about 80 per cent of the region's population was getting its drinking water from a protected source. Much of this progress has been achieved in the last two decades, largely through institutional initiatives in expanding the penetration of public supply systems and technological innovations, such as inexpensive but efficient handpumps.

But as with the other indices of well-being, the progress on this has to be suitably qualified by caveats. Because of systemic inefficiencies, at any given time between 20 and 25 per cent of public supply systems in South Asia are not operational. Besides, public supply has a marked urban bias. In a region that is predominantly rural, 90 per cent of urban residents receive adequate water, while only 70 per cent of the population in the countryside have access to this amenity. An estimated 50 million people, many of them rural, meet their water requirements from unprotected surface sources.

Ground water is generally considered to be relatively more free from contamination than surface water. However, the South Asian situation is complicated by a variety of factors. Faulty borewell construction and irregular or inadequate chlorination make ground water susceptible to contamination. Because there is no quality- surveillance mechanism in place, problems of this kind could go entirely unnoticed until they announce themselves through various chronic illnesses.

Population pressure poses an additional problem. Increased use of ground water has begun to affect the aquifer. In combination with the extensive reliance on ground water for irrigating commercialised agriculture, this has led to depletion. More than 70 percent of the fresh water extraded from the ground is put to agricultural uses, and the annual rate of depletion is greater than replenishment.

This is the paradox of ground water use in South Asia. The greater the number of people who are given access to this safer source, the sooner they lose access to it. Profligacy of ground water use makes it more prone to contamination by natural chemicals through the process of leaching. Fluoride and arsenic are the two most lethal contaminators of ground water. The geographical spread of both has assumed alarming proportions.

This series of maps in sequence illustrates the gap between what should have been available to the region by way of safe drinking water and what is actually available after accounting for contamination and depletion. The area in green, in the first map represents the fairly high availability of safe drinking water. This begins to shrink when the area of fluoride contamination is mapped on it. The mapping of arsenic contamination, which is high in Bangladesh, West Bengal, parts of Nepal, Pakistan and Afghanistan, curtails the green area even more. By the fourth map, following the addition of ground water-depleted areas, the area in green is only a fraction of what it started at. If the situation is not rectified, South Asian children will face new dangers from water-borne maladies, even as old diseases continue to persist.

Maternal & infant mortality

Every two minutes a South Asian woman dies due to complications arising from pregnancy and childhood. This adds up to half of all maternal deaths in the world. Nearly 15 per cent of women who die during and after pregnancy are victims of violence, and in some areas the proportion of those who succumb to violent injuries is greater than those who die of obstetric problems.

More than 40 percent of the girls in South Asia bear children before they are 20 years old. Teenage pregnancy, which is as high as 15 percent in South Asia, and which involves five times greater risk than pregnancy in the 20-25 age group, has a role in the extraordinary magnitude of maternal deaths in the region. These bare statistics suggest that a large number of maternal deaths need never have taken place.

Apart from the social and accidental causes of maternal mortality, there are the purely medical causes. The immediate medical causes of mortality are haemorrhage, obstructed pregnancy, unsafe abortion, infection and hypertensive disorders like eclampsia .

There are also indirect obstetric causes of maternal death, arising from already existing diseases or diseases occurring during pregnancy. These include anaemia, hepatitis, malaria and cardiac disease. Death in a lot of such instances can be prevented given the availability of emergency obstetric services (EmOC).

South Asia has the technical capacity and the trained personnel to provide emergency obstetric services. The problem is that most women lack access to such facilities. Mismanagement of available public services is also a problem. Less than 5 percent of the existing EmOC facilities provide adequate emergency services.

One indication of the lack of access to professionally qualified services is the number of deliveries conducted at health institutions. Barring Sri Lanka and the extreme south of India where more than 75 percent of the deliveries take place under medical supervision, in most of the region, less than 25 percent are attended by qualified personnel. The graph merely confirms what could reasonably have been surmised—that access to professional medical assistance is lowest among the poorest segment of society.

Aside from institutional interventions to ensure obstetric services, there are fundamental longterm situations that have to be addressed. Anaemia is an instance of a problem that cannot have a purely medical solution. It is essentially a dietary matter. Almost 80 percent of pregnant South Asian women are anaemic. Anaemia among pregnant women, besides endangering the lives of both the mother and child, can have long term consequences for the child in terms of brain development.

As the anaemia map suggests, iron deficiency is a general condition of women in large parts of South Asia, and this will have its cummulative effects for some time to come in as much as it will continue to obstruct the goal of reducing under-five mortality and and malnutrition among children.

The medical aspects of maternal mortality can be addressed through higher budgetary allocations and their efficient utilisation for the extension and upgradation of obstetric services. But the social causes of maternal mortality, like teenage marriage and pregnancy, violence against women, and the prejudices and superstitions associated with pregnancy, will be by far more difficult to tackle since they require a different order of intervention.

As a beginning, it is possible to introduce legislation that will strengthen women's rights. But in a region that is notoriously lax in observing the law, this is only a necessary condition. The sufficient conditions can be created only through wider changes in civil society, in family relations and social attitudes.

Gender Disparities

South Asia is unmistakably gender biased, with a record of discrimination against girls and women that is abysmal. Discrimination begins with the birth of the girl child and continues through her lifetime, manifesting itself in poor infant care and nutrition, differential childhood treatment, inadequate education, early marriage and financial dependence. In most work situations they have to work longer hours but get paid less than men. This makes them more vulnerable to poverty despite the fact that they often do more strenuous work than men.

South Asia prefers sons to daughters and an adverse sex ratio for girls, a trend at variance with the global norm, is proof of this. For every 1000 men, there are only 940 women. For many death comes before birth or soon after. Socially sanctioned "son preference" is at the root of female foeticide and infanticide. In the state of Gujarat in India, about 10,000 female foetuses are aborted every year. In any society, the number of missing males and females should be about the same. But in South Asia it is estimated that at the turn of the millenium, between 70 to 90 million women are missing. Current trends indicate that in the course of the next decade, the number of missing women will go up to 120 million.

Ironically, the availability of modern technology such as Magnetic Resonance Imaging has made sex-selective abortion of female foetuses a lot easier. The unborn daughter is a conspicuous absentee in gender demography of South Asia. As the map indicates, barring a few pockets, across the region more boys are born than girls, with a fairly large area where there are less than 900 females per 1000 males.

Another area of obvious discrimination against the girl child is education. South Asia is more attentive to the boy's education. The trends in net enrollment as between boys and girls show quite clearly that a cultural choice is exercised in equiping the male. The areas of low female enrollment are also areas which show poor trends in other areas of child development as well, such as malnutrition and immunisation. The likelihood that these other poor indicators reflect to a greater extent the condition of the girl child than the male child is therefore very high.

Poorer girls are less likely to escape the cycle of poverty than poorer boys. Trends in grade nine completion by sex and wealth suggest that where hard economic choices have to be made, the benefit will accrue to male children. A fairly large part of South Asia shows the most positive trends for grade nine completion by poor boys. Contrast this with equivalent educational attainment by poor girls. The most negative trend accounts for the bulk of South Asia geographically.

Even considering basic literacy, the figures are not particulary encouraging. Female literacy rate has shown only a very slight improvement in the last decade. The situation is particularly dismal in Bangladesh, India, Nepal and Pakistan which began the decade with low female literacy figures and ended it with only marginally improved figures. Even the dramatic increase that Bangladesh registered in the late 90s has not helped very much, with a current female literacy figure in the vicinity of 40 percent.

By all indices, girls in South Asia are being groomed for domesticity and early motherhood: 15 percent of the pregnancies in the region are among girls below 18 years This phenomenon then reflects itself in other spheres, like maternal and infant mortality and obstetric complications. Clearly, tackling institutionalised discrimination is a prerequisite for addressing many of the other problems that affect children in South Asia.

Child labour

Child labour is an economic reality that will require long term structural changes. But in South Asia, which is home to some of the worst forms of child exploitation, an immediate measure to curb some of its more pernicious forms could be to strengthen the legal provisions to regulate the age of entry into organised employment and the conditions of their work.

The current legal environment is pitiably inadequate to ensure the prevention or regulation of children's work. Approximately 43 million children in the age group 5-14 are in the active labour force of South Asia. What compounds the tragedy of these alarming figures is that a large number of them work in hazardous industries, and suffer from premature physical debility. In effect, many child workers have neither a childhood nor any meaningful adult life.

The International Labour Organisation's Convention 182, calls for protection of children under 18 from the worst forms of child labour. But recent changes in the manufacturing sector in South Asia, particularly the expansion of the so-called informal manufacutring units, has made it more difficult for governments to control child exploitation. Informal sector units do not come under the ambit of protective labour legislation, which enables unfettered exploitation both in terms of wage and conditions of work. As a proportion of the total child work force, India has the largest number of children in the manufacturing sector, followed by Sri Lanka and Pakistan. Roughly 8 percent of working children in South Asia are employed in match and fireworks production, gem polishing, glass and metal work, all of which are hazardous.

Aside from employment in hazardous industries, another major area of child exploitation is the trafficking in children. The volume of trafficking has increased despite growing awareness of the problem in recent years. Trafficking takes place both within the region as well as to West Asia, South East Asia, Hong Kong, North America and Europe. In India alone some half a million girls are victims of trafficking. A large number of trafficked children end up performing sexual services. An estimated 20 percent of the prostitutes in South Asia are children under the age of 16, some of them being as young as 8 years of age.

The problem of trafficking is additionally complicated by the fact that despite the commitments made to uphold the Convention on Child Rights, there is no coherent juvenile justice system in South Asia. As a result, many of the victims of trafficking also often become victims of the law being detained in police custody, ironically enough, for trafficking offences.

HIV & AIDS

For a  disease that arrived only fairly recently in the region, the first case being reported in India in 1986, HIV /AIDs has claimed a large number of victims. And for a disease whose spread is dependent almost entirely on individual behaviour it has continued to grow despite the continuous awareness campaigns. By the year 2000 there were more than 4 million people living with HIV/AIDS. Of these, more than a million were in the age group 15-25. And, by far the most disturbing aspect of AIDS in South Asia is that already 125,000 children have been orphaned by the disease.

Though HIV/AIDS is commonly perceived to be a predominantly African problem, the statistics suggest otherwise. South Asia has one of the fastest growing AIDS epidemic in the world. The combined figures for South and South East Asia indicate that one young person gets infected every two minutes. In India, infections doubled between 1994-1998.

Between 75-80 percent of H1V transmission occurs through unprotected sex while 5-10 percent happens through sharing of needles by drug users. Studies suggest that adoloscents and young adults constitute a high risk group in both forms of transmission. This has serious consequences for a region in which as much as 54 percent of the population is below the age of 25.

The experience of countries with high AIDS prevalence show that infections among young adults can have debilitating econonomic effects. A South African study projects that by 2010 the real GDP of the country will be lower by 17 percent than would have been the case in the absence of the disease. A study on India estimates that for the year 1991, the loss of productivity due to AIDS in monetary terms adds up to a staggering Rs 1014 billion.

Since AIDS is an expensive disease to treat, prevention is a cheaper alternative since prevention is largely a behavioural rather than a medical matter. What makes for an optimistic prognosis is that at the current rate of transmission, countries in the region still have a few years to go before the epidemic starts shifting from high risk groups to the general population. If the tragedy is to be controlled the time available has to utilised effectively.