The chairman of this afternoons session and in fact the last five speakers have all been from UNICEF and the real reason that I'm up here is to try and demonstrate that WHO is also doing something. I hope you'll be convinced. This morning Richard Jolly mentioned five aspects of following the foot steps of Jim Grant. The fifth of those was attention to the details. What I'd like is to focus on at least a few of those details. There was no mid decade goal set for Acute Respiratory Infections but somehow it appeared on the program and I'm not going to miss the opportunity to say something about this condition, the single cause of death in children. Every day millions of parents, mostly mothers like these take their children for health care. Three quarters of those children, if sick have one or more of just five common conditions. Every day 33 000 children die. Most of these deaths could have been prevented. Most of them are caused by the same five common conditions. I would like you to study the details of this pie diagram just for a few minutes. It should be a striking diagram. If it isn't, its because we are so bombarded with numbers and facts, that we have become unreactive. We must let the facts guide our actions as was suggested a short while ago by Peter Adamson. It is clear from this slide that there are a few conditions which contribute in a major way to the cause of death of children and of course these are mostly children in the developing world.
Acute Respiratory Infections mostly pneumonia and diarrhea are the two most important single causes of death. I would like to draw your attention as well to this number sown here, it says that 71% of all deaths in children less than five are associated with one or more of these conditions. Surely that is a striking fact! Let me start by talking about ARI. What we are trying to do in tackling this problem is in essence quite simple. Making it happen however, requires an enormous global effort. The priorities as shown in this slide are first, the training of health workers to detect pneumonia using two simple signs, the breathing rate and chest in drawing. Health workers have to be able to do this to detect pneumonia in places which have no laboratory services, which have no x-rays and in fact have very little equipment at all, and they can be taught to do this. Second, we need to train health workers in the correct use of antibiotics and we need to do this quickly. Of course we need to help work with governments to plan programs and to evaluate those programs to make all of this happen on a large scale. One thing we do need to give attention to is monitoring antibiotic resistance patterns. We shouldn't exaggerate this problem, but it does exist and we do need to be on top of it. I don't want to be to scientific but I would like to draw your attention to an important fact. That is that most of the treatable pneumonia which occurs in children is due to just two bacteria, two organisms; streptococcuspneumoniae and hemopholous influenza. They are probably names that don't mean too much to at least some of you.
Each year, these two bacteria kill about 1.5 million children. Since the start of the Ebola virus outbreak in Zaire a few weeks ago, these two bacteria have taken the lives of approximately a thousand times more lives than the Ebola virus. Yet they have not been mentioned once in the newspapers as far as I know and they have not been the center of a major Hollywood production, which has captured the imagination of large populations. Although the largest single killer of children receives little attention. We are however, through the efforts of WHO, UNICEF, and other agencies but particularly through the efforts of governments in developing countries doing something about this problem. Some eighty countries have now got programs dedicated to reducing mortality from acute respiratory infections. Countries where the ARI program strategy is most likely to have a great impact, are those with an infant mortality rate of greater than 40/1000. And as you can see, some 59 of those countries now have implemented activities for the control of ARI. Just as one example of the enormity of the effort that is required, let's have a quick look at the training in ARI, that took place in 1994. Thirteen hundred people were reported to WHO as having been trained in program management in eighteen countries. Some 12,000 doctors and 25,000 other health staff were trained in ARI case management in 58 countries. Over 10,000 community health workers were trained.
To date, some 280 ARI training units have been established in 38 countries. These are big numbers, but they are not big enough, and this effort to deal with ARI till lags far behind compared with the magnitude of the problem. What has been the impact of these efforts to date? There have been surveys conducted in eleven countries, and just quickly I'd like to go through the findings of those surveys. These surveys were conducted only in areas where program implementation had taken place. They showed about 44% as a median of health workers, had been trained in standard ARI case management. 70%, or 68% of these facilities had the first line antibiotics available. That's quite a large number, but it means that 32% of health facilities did not have available these very basic and essential drugs. About half of the facilities surveyed, had the capacity to provide standard case management. There is certainly lots of room for improvement. The same surveys looked at what proportion of the pneumonia cases were correctly managed, not much more than a third of them. Also, about a third of mothers were correctly advised on how to deal with the pneumonia at home. And about a third of all ARI cases inappropriately received antibiotics.
Perhaps the most positive thing we can say about these numbers is that we have them, because for many years we have not had good numbers on the management of ARI. This gives us a better opportunity to target our programs. What are the future challenges? Well, not very surprisingly, among them is expanding the training coverage to all health workers. We still have a long way to go. And once trained, these health workers need supportive supervision and careful monitoring of their work. We need to ensure the availability of free or affordable and effective antibiotics in all health services. And we need effective communication with all families using appropriate language and terms that they can understand, so that they will bring their children for care when that care is needed urgently. And lastly, as I mentioned, we need simple methods for monitoring antibiotic resistance patterns and clear guidelines for when policies should be changed. Let me turn now to diarrheal disease. This is an image of a mother giving her child life-saving, oral rehydration solution, an image which fifteen years ago was almost unseen and today is common-place. I'd like quickly to explain to you what we need to in relation to diarrheal disease in order to significantly reduce diarrheal mortality.
There are three main types of diarrhea; acute water diarrhea, persistent diarrhea and dysentery. In this column you see the distribution of the cases in today's three categories, most of them are acute watery diarrhea. However, when we look at the deaths, acute watery diarrhea accounts for only 50% and the other 50% are accounted for by persistent diarrhea and dysentery.
Therefore, if we want to tackle the problem of diarrheal disease, we need also progressively to address these two types of diarrhea. As you see, the treatment in each case is somewhat different. For all cases, we need oral rehydration therapy and continued feeding. And in a few cases, intravenous therapy. For persistent diarrhea, we need dietary management and for dysentery we need appropriate use of effective antibiotics. At home, families should increase fluids and keep feeding, as well as seek care if the danger signs appear for acute watery diarrhea. And they should also seek care if the diarrhea persists or if there is blood in the stools. When we talk about dietary management, as I did in the previous slide, for the 10% of cases of persistent diarrhea we are not talking about this. This brochure was given to us by a doctor working in Bangladesh. It's message is clear and clearly wrong, except for the small message which promotes breast feeding, which you'll find down here. In my overview of diarrhea management two slides back, the use of drugs except for antibiotics in dysentery was not mentioned. And yet every year, between one and two billion dollars are spent on drugs to treat diarrhea in children. Some of these drugs are harmful, most of them are useless. This slide, I think, tells a story. The name of the drug shop promises cheap drugs. This is certainly a lie, for these people, these drugs are certainly expensive. The drug seller almost appears to be rubbing his hands with glee at the prospect of selling the drugs. It's clear what his motive his. The father, let's assume it's a father, seems to be looking at this rather large collection of drugs and asking himself; Do I really need to buy all this? But in fact he also feels that he doesn't have a choice. If he's told this is what will save the life of his child, then he feels obliged to spend the money. That money would certainly be better spent on something else, food for example. So how much has been achieved in diarrheal disease control? A great deal. Diarrhea treatment charts, like this one, which happens to be in Russian, I can't see without my glasses, can be found in most countries of the world. This approach, the approach which is outlined in these treatment charts has become the standard. Although unfortunately, not a standard which is always followed, especially in the private sector. But the way in which diarrheal disease is tackled, compared with how it was tackled fifteen years ago is a dramatic change. This slide shows the increase in RRS supply. The topic of this afternoon session or part of the topic was achievements. This is surely a great achievement of the world's public health community. The expansion and the supply of RRS from here to where we are in the mid 1990's. And that's particularly important to note about this, is that this green bar represents the RRS, which is produced in the countries where diarrhea is a problem. Over 75% of all RRS is produced in such countries. And not only has the amount of RRS going into the supply system increased, but so has its availability.
One of the targets set by WHO and UNICEF in 1990, a process target if you like, in order that the World Summit for Children goal of a 50% reduction in diarrheal mortality might be achieved, was a goal for access to RRS. It was set at 80% for 1995, and as you can see here we are close to achieving that. But on the other hand progress has leveled off somewhat. We will certainly need another boost of energy and effort to achieve the year 2000 target of 100% access to this life-saving remedy. Another goal which was set, was for caretakers knowledge of the three rules of management of diarrhea in the home. These three rules are increased fluids, continued feeding and knowing when to seek care. We started to measure this only in 1993, and here the findings are somewhat less encouraging, we're at about 18% from 1994. But if we break it down into each of the three rules separately, the picture is somewhat more optimistic. In fact it is very optimistic. Most mothers now know, perhaps they always knew to continue feeding during diarrhea. Also most know to increase the fluid intake. And it's the third aspect, about when to seek care, which is clearly the limiting factor for this indicator and which we need to give some attention to. Of the mothers who knew the need to increase fluid intake, how many did so?
This slide shows the proportion of diarrhea episodes receiving either oral rehydration salts, or a recommended hyme fluid. 56% in 1994 and an encouraging steady upward trend. The last indicator, which we agreed with UNICEF, and the most important, is the proportion of diarrheal episodes receiving both oral rehydration therapy and continued feeding. Jon Rohde, has long said that diarrhea is a nutritional disease and it has taken us a long time to build continued feeding in as an equally important component as oral rehydration therapy in management of diarrhea. We had originally set a target of 50% which we thought was realistic for 1995, and you can see that we're quite close to achieving that target. But in agreement with UNICEF, a few years ago, we set a higher, more ambitious target of 80% for 1995. As Dr. Nyi Nyi has mentioned, we probably will not achieve this target by 1995, but let's hope that we will achieve it shortly after. Is all of this having an impact? Those of you who heard the Minister of Health from Mexico speaking this morning, would have heard him mention these numbers. He didn't show the slide, but this is an impressive decrease in diarrhea mortality in children less than five years old in Mexico. The CDD program in Mexico started around here and there was a period of ten years or so of intensive activity training health workers. In 1991, cholera struck Latin America and there was an intensification of diarrhea control efforts. And in 1992, there was an even greater intensification with a great deal of political commitment, starting with the president of the country. There has been a dramatic decrease in mortality in the last few years. Probably that would not have been possible despite this increased effort, if there had not been a ten year period before in which the program had built a firm base. A few challenges for the future. First, maintaining and expanding the use of oral rehydration therapy and continued feeding to all episodes of diarrhea. Improving the management of persistent diarrhea and dysentery. And here, I make a special plea to medical colleagues in the audience.
We really need to do something about persistent management and dysentery management in health facilities. Diarrhea is not a problem which can be tackled only in the home. It has to be tackled also through appropriate care in health facilities. Thirdly, reducing the use of anti-diarrheal drugs and the inappropriate use of antibiotics. Let's use some of this one to two billion dollars, which is spent for this purpose more wisely. And fourthly, completing research, particularly on improved RRS solutions, and the treatment of diarrhea and severely malnourished children. A large proportion of deaths that occur in children with diarrhea, particularly those from persistent diarrhea, occur in malnourished children. Most of what I've said has been about treatment, and I did intend to say something about breast feeding, I won't say much because that topic was fairly well covered. But just let me say that breast feeding is probably the most important preventive intervention which exists for diarrheal disease. It's extremely powerful, it's low cost or no-cost if you like and it's universally available. A child-friendly world is not a world in which millions of dollars are spent undermining breast feeding and where we have to beg for funds in order to carry out programs for the promotion of breast feeding.
Just as health workers can be taught to treat sick children, so they can be taught to counsel and support mothers about breast feeding. WHO and UNICEF have jointly developed materials for this purpose. The should be used and they should be used widely. To conclude, let me come back to where I started. Shown here in yet another graphic representation, and we are always seeking ways of trying to make the message stick and it doesn't seem to, is the message that seven out of ten childhood deaths are due to just five cause. I have focused on our efforts to deal with two of them. But in reality, sick children often have more than one illness at a time. They don't come in conveniently with just diarrhea or just acute respiratory infections. The appropriate way to deal with these conditions is to address them all together. To address the sick child, not the individual disease. With UNICEF, we at WHO have developed an integrated approach to management of the sick child. I would urge you to take a look at the stand which we will have, which tells you briefly what this initiative is all about, and to become involved in it. By the year 2000, we hope that many countries will be adopting this integrated approach. In the meantime, we must use the proven tools we have available, we must listen to the facts, we must as Jon Rohde said; "Get on with the job", of tackling ARI and diarrheal diseases. The noble idea of the summit goals, which is in a sense what brings us all together here today, cannot be achieved without tackling these two killers of children. Thank you.