Send food, water and toys

Academics tackling issues such as HIV/Aids, child mortality and wellbeing in the third world are developing holistic, community-based healthcare. Mandy Garner reports.

About a third of all children under five in developing countries are malnourished. In the past, relief agencies have targeted basic needs provision such as food and clean water for the poorest of the poor, but they now look beyond the mere survival of such children. Experts are studying the effects of malnutrition on long-term health and the role of play in mental development.

Sally McGregor is a leader in this field. She has worked in child health for 35 years, particularly in Jamaica, and has spent the past five years at the Centre for International Child Health at Great Ormond Street Hospital in London. Her research focuses on sub-Saharan Africa and Bangladesh, and includes studies of zinc and iodine deficiency, low birthweight and parasitic infection.

But it is her work on the importance of play that is probably the most remarkable. And it has succeeded in putting play firmly on the development agenda. The World Health Organisation manual on child malnourishment now includes a section on toys, and Unicef cites McGregor's research in its material. McGregor was in Bangladesh recently when she came across a Unicef representative who was using CICH data to construct play programmes. "It was very encouraging," she says.

She is just beginning to work with Aids orphans, who she says do not get the psychological help they need. She says countries in sub-Saharan Africa hit by Aids "need international aid like hell - there is no way the governments can manage". About 11 million children in the region are Aids orphans.

The CICH takes a holistic approach to health, looking at how everything from malnutrition in the womb, post-natal nutrition and mental health are linked. For instance, poor nutrition can cause behavioural problems, increased anxiety and depression.

"We have got past survival," McGregor says. "But if these kinds of problems affect more than 30 per cent of the population, the effects to national development can be devastating. The waste is overwhelming. Millions of children are going down the drain."

The research projects undertaken by the CICH, which has just celebrated its tenth birthday, cover four main areas: perinatal care (which concerns the period shortly before and after birth), nutrition and infection, child development, and disability.

One pioneering scheme is looking at mother-to-child transmission of HIV, again from a holistic perspective. In some countries, more than 35 per cent of mothers are HIV positive. In the UK, HIV-positive mothers are advised not to breast feed in order to reduce transmission to children.

Following this advice can be expensive in developing countries and it has to be balanced against the health benefits of breast milk. Only a third of HIV-positive babies in developing countries are estimated to be infected through breastfeeding - the other two-thirds are thought to have been infected in the womb or in childbirth. It is unclear why some become infected while others do not. Andrew Tomkins, the CICH's director, says it may be genetic, but nutrition may also play a role. CICH research in some developing countries has found that the fact that many mothers mix feeding, using formula and breast milk, increases the risk of transmission. This is because mothers who mix feeding are more likely to suffer from infections such as mastitis, which can increase the viral load. Research has found that cows with a diet that is poor in antioxidants are more likely to develop mastitis.

Other more general research is looking at ways of increasing the quality of breast milk from mothers with poor diets by getting them to take vitamins and mineral supplements - but, Tomkins says, it is difficult to get a formula with a taste that is appealing. A project in Zambia is monitoring pregnant women through the birth of their babies and beyond to see how their breast milk changes, how adding nutrients affects child development and whether improved lactation counselling can make a difference.

The CICH has links with universities overseas and works closely with various non-governmental organisations and ministries of health. Much of its work serves to underline the gross inequalities between the health of poor children in developing countries and the average child in the West. David Osrin is a CICH research fellow working on a perinatal project in the rural areas of Nepal. He says that in Nepal about 93 per cent of women have their babies at home. Some 11 per cent give birth alone, while 10 to 20 per cent are assisted by a healthcare provider or traditional birth attendant. These women often have no contact with hospitals in the perinatal period.

Maternal mortality in Nepal is about 539 per 100,000 births - compared with just seven in the UK. Infant mortality has fallen in the past few decades as better treatments have cut the number of deaths of children under the age of one from respiratory diseases and diarrhoea. The expansion of immunisation programmes and a rise in standards of living have also contributed to better infant survival rates. But in the past ten years, the situation has stabilised and no further improvements have been noted. Osrin says two-thirds of infants who die before the age of one die in the first week after birth; half of these within the first 24 hours. The aim of the CICH and its partner organisations is to try to discover the reason why and to reduce the number of deaths.

"Many, many women and babies have problems that would upset people in this country if they heard about them," Osrin says. "One female member of staff died of post-partum haemorrhage just a week after she started work with us."

Among the main causes of death in women are septic abortion, haemorrhage, eclampsia, obstructed labour and general infection. For babies, major factors are complications in labour, infections and respiratory disease.

The three-year-old CICH perinatal project is based in the community rather than in laboratories or hospitals because many people in rural areas find it difficult to get to hospital. Much of the first years were spent in talks with local community groups, such as women's groups and local VIPs, ensuring that the project's goals were understood. It appears to have succeeded. Osrin says: "Most women appear enthusiastic because their voices are being heard."

The project trains local women to talk about infant and maternal mortality and the factors that can affect these. "They are helping us to understand the situation," Osrin says. "The aim is that people come up with self-generated solutions to the problems."

The women discuss subjects such as what they do if they encounter problems in childbirth, how they can tell if the birth is not going well, what they do when they are pregnant and what constitutes their diet.

Part of the problem, Osrin says, is that pain and illness are seen as normal in poor rural areas. Also, women are traditionally not encouraged to demand help or support. The perinatal project is part of a larger study to develop a sustainable, cost-effective model for improving child health. The Nepal project is one of 12 involved in a randomised trial to find out if the measures it adopts will make a difference. Its outcomes will be compared with those in another 12 countries that do not adopt the measures.

The treatment of the disabled is another area that reveals marked inequalities between developing countries and the West.

According to Sheila Wirz, senior lecturer in disability studies at the CICH: "People with disabilities do not get any services in most developing countries."

One of the main thrusts of her work is to ensure that disability is integrated into all health programmes, such as Aids prevention. "We know that women with disabilities are more likely to be HIV positive because they are more likely to be victims of abuse and yet, for example, women who are deaf seldom have access to HIV-awareness programmes," Wirz says.

Despite the effects of poor nutrition, consanguinity in marriage and war in developing countries, the disabled make up about the same percentage of the population in those countries as they do in the West. This is because many of the most severely disabled die in the womb or soon after birth. Also, mild learning disabilities that would be picked up in the West tend not to be noticed in developing countries.

Nevertheless, developing countries have a higher level of disease-related disability, more work-related accidents and a growing number of children suffering head injuries as a result of traffic accidents.

This last statistic boils down to yet another effect of poverty. "Vehicles don't have MOTs and the brakes are often lousy," Wirz says.