Simple as that, child mortality is at a record low

The first page of Alfred Malunga's fat village register is taken up by a single family. Mother, father, five children, the last a baby girl named Molly. A red cross has been inked in beside her name.

“I use that sign when someone passes away,” explained Mr. Malunga, the village health worker who maintains the register, two volumes long and 12 centimetres high. “That child died of malaria.”

But turn the page. And the next. There are no more red crosses for 10 pages. Molly is the only child in her village to have died in the past six months.

This is a startling thing in Malawi, one of the poorest nations in the world, chronically short of food and with less than $10 a person spent on health care each year.

And it is part of an equally startling trend: Deaths of children under the age of 5 declined 29 per cent between 2000 and 2004 in Malawi. This country is one laboratory in a health-care revolution that is quietly yielding spectacular results across the developing world: The application of a handful of simple, low-cost measures, from giving families $2 mosquito nets to encouraging breastfeeding, is spurring a sharp decline in child deaths around the world.

For the first time since the United Nations began to keep records in 1960, the number of child deaths fell below the 10-million mark, down to 9.7 million in 2006, the last year for which there is data.

“This really is a historic moment,” said Peter Salama, Unicef's chief medical officer, although he was quick to note that those 9.7 million deaths, almost all of them from preventable or easily treatable causes, are “in no way acceptable.”

Nevertheless, this is undeniable good news from developing countries, made even brighter by the fact that the biggest drops in child deaths have come in some of the poorest places: 20 per cent in Niger, 23 per cent in Mozambique, a stunning 41 per cent in Madagascar. (Sub-Saharan Africa accounts for 50 per cent of all child mortality, even though the region's total population is only half that of India. In West and Central Africa, more than 150 of every 1,000 children born die before the age of 5, compared with fewer than six in Canada.)

Mr. Malunga knows what's responsible for the drop in his area: The biggest reason is that all pregnant women are now given a free insecticide-treated mosquito net for themselves and their children to sleep under. The new access to bed nets – which, even at a heavily subsidized price, are too costly for people here to buy, he said – has cut malaria deaths by about a third in the past few years. “It is malaria that kills most of the children,” he said.

But he is going after more than malaria: He has vaccinated nearly every single child in his 16-village territory – measles used to be a big killer here too, but there hasn't been a case in seven years, he said. No polio since 1990. He gives most children a capsule of vitamin A at least once a year, sometimes twice, if he can get it – and that is enough to boost their immune systems so that if they do get diarrhea or malaria, they are much less likely to die.

He weighs the children every time he sees them, and plots their growth on a chart – in Malawi, 46 per cent of all children show signs of stunting, the result of chronic malnutrition – and refers any who aren't growing well to the emergency nutrition rehabilitation centre. He has persuaded more and more women to breastfeed their babies and delay any introduction of solid food until the age of six months. Traditionally women here give babies maize porridge from the age of one week.

Mr. Malunga has supervised the installation of cement-covered pit latrines and protected water sources in many of the villages, leading to a drop in water-borne illness. He has persuaded many women to take contraceptive pills or get the Depo-Provera injections he does in the clinic – because, he explained, children spaced at least two years apart have much higher chances of survival. He travels village to village talking to groups about HIV (with which 14 per cent of Malawi's adults are infected) and he offers them condoms.

As proof of how well all this is working, he stops on a tour of the village outside the one-room mud-brick house of Ruth Mtalika, where she sits nursing her three-month-old son Skevas, a child so enormously fat that he resembles a miniature Sumo wrestler, and blissfully cheerful. Mr. Malunga helped her get a bed net, and told her about nutrition when she was pregnant, Ms. Mtalika said; now he frequently reminds her about breastfeeding and he gave Skevas his first vaccinations. “He is a very healthy child, and that makes me glad,” she said, tickling the mountain of baby in her lap.

The main package of interventions Mr. Malunga offers (vaccinations, vitamin A, antenatal care, breastfeeding promotion and bed nets) was tested in a Canadian-funded pilot in 11 countries in West Africa and in 2003 was shown to reduce mortality by 20 per cent. Canada is the largest funder, globally, of both vaccinations against the killer childhood illnesses (at a cost of about $10 a child) and of vitamin A supplementation, which typically costs less than five cents a child but cuts mortality by 23 per cent.

Indeed, the most striking thing about these interventions, beyond how well they work, is that they are not, as the saying goes, brain surgery. They are ludicrously cheap and easy to deliver. Kenya, for example, cut child deaths from malaria by 44 per cent in the past four years simply by giving out for free bed nets that cost about $2.

“Really, it makes you sorry that it has not happened earlier,” sighed Habib Somanje, the director of preventive health services for the government of Malawi. One obstacle, he said, is that unlike curative health measures, such as building new clinics, preventive health care is not considered exciting either by donor nations, on whom Malawi is hugely dependent, or the voting public.

So he has battled to get the resources to fund initiatives such as the bed net distributions – currently just half of children sleep beneath nets, but his ministry will give out two million more this year, aiming for total coverage in a couple of years. Through simple education programs (sitting women down beneath the biggest tree in a village for a lecture), Malawi raised exclusive breastfeeding from 7 per cent of women to 63 per cent, between 2000 and 2004. But tree-shade lectures aren't as flashy as new wells or blood pressure machines.

The early-childhood package is good, but when Mr. Malunga tallied what has worked in his 16 villages, he left one critical factor off the list: himself. The child-survival interventions have been introduced across sub-Saharan Africa but not every country has posted the gains Malawi has. What Malawi has that no one else does is Mr. Malunga, and 3,500 other community health workers.

For the 1,740 people in his registry book, he is the primary source of contact with Malawi's chronically understaffed and under funded health system. “I serve the people much better because I am here and they can come to my house at any time,” he explained.

Mr. Malunga, 31, has only a Grade 10 education and received just eight weeks of training when he began this job more than a decade ago. Often his small clinic lacks even Aspirin. But he is enough to guarantee good vaccination coverage, early diagnosis of respiratory infections and malnutrition – enough, in short, to cut child deaths by nearly a third.

Many developing countries have recognized that they need a way to get preventive health care and information out from district centres to rural and poorly educated populations, and there have been all manner of schemes to train community health volunteers. But very few countries have been willing to do what Malawi does: pay them. It's only $36 a month – not even enough, Mr. Malunga lamented, to buy a bicycle – but in a desperately poor country, it is enough to keep him showing up in a crisp blue polyester uniform to weigh and vaccinate babies each day.

“Nowhere has had success with this except Malawi,” said Juan Ortiz, the deputy head of Unicef's mission here. “And it works in Malawi because they pay them.”

Now this message, too, is spreading. Ethiopia, for example, is finalizing training for 30,000 community health workers who will be paid (if minimally) as civil servants and who will supervise the key early-childhood interventions. They are trained to spot respiratory infections and pneumonia, and refer to clinics; they can treat diarrhea with oral rehydration salts. Dr. Somanje said that Malawi is convinced of the value of its community health workers and is training and recruiting 6,500 more.

There are larger factors at work in Malawi and beyond, of course: In India and China, the major drops in child mortality have much to do with the fact that as economies boom, more kids have access to adequate nutrition and health care; girls get married later and have fewer children, both of which are key indicators for better child survival. Dr. Somanje said that this is even happening in Malawi (where there is nothing that could be construed as a booming economy) because primary education was made free in 1994. As a result, there is a new generation of young women with primary education, and they are delaying marriage and childbirth.

Unicef's Dr. Salama predicted that child mortality rates will continue to fall, at an even higher pace, in Malawi and across the developing world over the next few years, as these cheap and easy interventions are adopted more and more widely. In addition, these data cover only up to 2005, and so do not reflect much of the impact of the massive injection of cash into areas such as vaccination and malaria control that have come from agencies such as the Bill and Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

But within a couple of years, the low-hanging fruit, as Dr. Ortiz described it, will be picked, and then saving children gets more complicated. The children for whom Mr. Malunga can do little are those whose mothers bring them to him when they have severe diarrhea or complicated pneumonia, which kill quickly. It's been more than a year since he had even the simplest antibiotics in his small medicine chest. The process of drug procurement in Malawi is a national disaster, beset by corruption, mismanagement and theft, and basic drugs rarely make it to the village level. Last year, only 5 per cent of pregnant women with HIV had access to the drug that would prevent them from infecting their babies.

Mr. Malunga can refer children to hospital, but Malawi's health system is horribly short staffed (health-care workers die of AIDS at higher levels than the population at large, and desert the under funded system in droves for better jobs abroad; two-thirds of the country's nursing jobs are vacant, and there are just 100 doctors in the entire public health system) and often not much better than the village clinic.

“We need to scale up treatment; this is the next critical phrase,” Dr. Salama said. “But the services that demand a 24-hour treatment response from the health worker are more complicated than the simple outreach services that can be delivered by a very basically trained health worker and that don't rely on someone to be there all the time. The basic first-level health system has to be functional and so also has the basic supply and procurement system – if not, we're simply not going to make big gains.”

There are two other major obstacles in Africa: Countries such as the Democratic Republic of Congo involved in continuing conflicts show little progress in lowering child mortality; and in southern Africa, the ravages of the AIDS pandemic are undermining and even reversing gains, as in Zimbabwe, that had been seen until recent years.

But Dr. Ortiz said that the lesson from Malawi is that with real commitment from government and financial help from rich nations, any country can bring down child deaths.

“People are always looking for silver bullets – a new technology, a new intervention, a new discovery,” Dr. Salama said. “What we've learned is that the focus in child health needs to be less on finding a new silver bullet, particularly a technological one, and much more on delivering at scale these things that we know work.”