by Adanna Chukwuma

As long as we continue to lose our children to preventable disease, we not only perpetuate the unjust conditions that cause these deaths, we stall our progress as a nation. 

Have you been to a hospital nursery lately? The next time you visit one; randomly count eight children out of the crowd. Going by the 2013 Nigerian demographic and health (NDHS) survey, there is a good chance that one of those children you counted will die before her fifth birthday.  That’s an average of 128 deaths per 1000 live births. As saddening as that thought is, reality for Nigerian children seems to worsen depending on where you decide to count. Per 1000 live births, the number that die before five increases from as low as 90 if you live around Lagos to 185 if you live around Sokoto; from 73 among the richest households to 190 in the poorest; and from 100 if you live in an urban area to 167 if you are a rural dweller.  Too many figures for a first paragraph, I know. The point is – our children are dying, especially the poor, rural and Northern.

 

The obvious follow-up question would be “why are our children dying, aren’t we doing enough?” In a few words, like several other African nations, our children die primarily as a result of preventable and treatable conditions – infectious diseases including diarrhea, pneumonia and malaria; malnutrition; and causes of ill health that primarily afflict the newborn. A few more figures (forgive me!) in the report give us pointers to what might be driving these rates on average and the differences across regions: 1 out of 5 children does not receive a single vaccination on average (a figure which jumps to 1 out of 10 in the North West zone); 1 in 3 children are undernourished or too short for their age, a factor which puts them at risk for several other childhood diseases; less than 1 in 5 children receives appropriate malaria treatment or sleeps under an insecticide-treated net; and as few as 1 in 8 pregnant women receive skilled assistance at delivery in a health facility in the North West zone.

 

We have obviously not been docile and there are a number of local and national initiatives that aim to address this challenge through a variety of means – community nutritional interventions; mass distribution of insecticide-treated nets for malaria prevention; engagement of the private sector to increase uptake of appropriate malaria diagnosis and treatment; mass recruitment of community and other primary health care workers; cash transfers to pregnant women to get them to show up for care etc.  Several of these interventions are borne out of generic recommendations from international organizations to address childhood diseases in contexts such as our own.   However, while these diseases may have the same biologic causes, the social factors that affect their occurrence differ between countries (and across regions within countries as should be expected in the diverse mass that is Nigeria).  I will thus (briefly) claim that while these initiatives are commendable in themselves, we have jumped a few steps in deciding what to do, and that we certainly can do much more overall to address the challenge before us – eliminating preventable child death.

 

The optimist could point out at this point that the death rate among Nigerian children has fallen by 18 % since the last NDHS, indicating that whatever we are doing seems to be working. While this is probably true, our death rates are much higher than those seen in countries like Ghana and Rwanda, which despite resource constraints engineered faster falls in child death rates over similar time periods. I would be justified to stick with the argument that it is imperative to change this reality for millions of Nigerian children because we obviously have the resources to do so, I will not. I posit that there is yet another reason to act. Brief hint: within a household, the expectation of child death affects the decision of parents to have more children. Thus, in places where death rates are high, mothers do the math and have enough children to meet their desire for surviving ones. Reducing child death could then decrease the number of children women have on average, which in turn could potentially have a cascade of positive effects on the health and wealth of our country.

 

Heard of the term “demographic dividend”? It is the promise of accelerated economic growth for countries with a proportionally large, healthy, educated, and mobilized working age population. For many demographers, an important trigger for this process is reducing child death (It is important to stress that health improvement here is a necessary but insufficient trigger). Why? Because reducing child death, means fewer births overall and fewer maternal deaths in childbirth. Because fewer children mean more resources invested per child, and thus healthier and educated children.  Eventually, we will have a mass of young productive people, and given the right policy environment, our (now surviving and would-be) mothers will be enabled to join the labor force too, contributing to the growth of our economy.  Many experts consider the demographic dividend to be one of the main reasons behind the East Asian economic miracle. The accompanying policies to improve child and maternal health, the labor market etc., should spur a different kind of economic growth than Nigeria has hitherto experienced – one that has immediate implications for the standards of living of the average Nigerian – economic growth that is accompanied by human development. And it may well start with fast-tracking the reduction of child death.

 

If at this point you are convinced of the weight of the problem, and the imperative to solve it, I have three brief concluding thoughts. First of all, given scarce resources, we have to decide which children to give priority to. On a general note, a higher rate of child death seems linked to living in rural areas in the North and being poor. Thus while we must value each child equally and work to plunge child death rates across the board, a valid case can be made for prioritizing coincident disadvantage – exposure to multiple risk factors for child death, which could also contribute to exclusion from needed care.  More specifically, we would need to clearly characterize which children are at the highest risk of death in the different regions and make our effort proportional to risk, within the limits of efficiency – sometimes the cost of targeting will far exceed the benefits.

 

Secondly, there is evidence on interventions that reduce deaths from the causes that often beset our children – such as oral rehydration therapy for diarrhea; antibiotics for respiratory infections; artemisinin- combination therapy for malaria; and skilled birth; immunizations for vaccine-preventable deaths; and post-partum care for the numerous causes of death in the newborn.  The thing is, interventions do not deliver themselves, and despite our current efforts children are deprived of life-saving interventions. Thus, behind the high child death rates we see are the gaps in our understanding how best to get the interventions that work to the children that need them. For example, I stumbled across an evaluation of facility-based care for nutrition that showed that our mothers with undernourished children in the north were just not turning up at the clinic.  Were mothers getting care for their children at all? If they were, was this care appropriate? What made mothers opt for one point of care over the other? Were mothers even the ones doing the opting? I have a few hypotheses of course, but I do not know for sure the answers to those questions and neither do you most likely. My point? We need to move from prescription to diagnosis. We need more local researchers testing out models of health care delivery that connect households to health care, that surmount religious and gender-related barriers to access, and give us value for money. In summary, we need a lot more child health program and policy-relevant research.

 

Finally, fast-tracking the reduction of child mortality demands action beyond the traditionally-defined health sector – increasing household income, educating and empowering mothers, providing access to safe water and sanitation, and improving food security.  With much less financial resource, Rwanda “slashed” child death rates as a result of multiple determinants including broad economic growth, improving household feeding practices through local gardening, in addition to public health specific policies to increase vaccination coverage, mosquito net distribution, community-based care, and health insurance coverage.  (Caveat of course: Rwanda has a lot less ethnic heterogeneity than Nigeria, has a much smaller and dense population, which could make programming and targeting much easier. Nonetheless, Rwanda apparently has achieved some of the steepest declines in child death rates ever recorded. ) In a country with community norms and household wealth as diverse as Nigeria, this mix of interventions to reduce child mortality will probably be as varied sub-nationally. Thus at the state and local government level, we need to think about building the capacity to lead and fund concerted action across departments and agencies that may have hitherto functioned in siloes: action that is informed by an understanding of the causes of child death in each local context. The political difficulty of devolving power to enable this is not lost on me, but difficult is not synonymous with insurmountable. I suppose that could be the subject of an entire (next) opinion piece.

 

In the nurseries of today, could be the engineers, architects, and doctors of tomorrow. As long as we continue to lose our children to preventable disease, we not only perpetuate the unjust conditions that cause these deaths, we stall our progress as a nation. Making the leap between now and the promise of a better future demands action to protect the health and opportunity of the Nigerian child, enabling her to transition into a productive adult life.  We keep telling her she is the leader of tomorrow, well we need to act like we mean it.

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Dr. Adanna Chukwuma is a medical doctor, an alumnus of University of Oxford, who is currently studying for a doctorate degree at Harvard University.

Op-ed pieces and contributions are the opinions of the writers only and do not represent the opinions of Y!/YNaija.