HALPERN 41

A Child Survival and

Development Revolution?

Robert Halpern I

Summary

This paper addresses the problem of child survival and development and
the challenge of reducing infant mortality in developing countries. It dis-
cusses the biomedical causes and the concomitant social determinants of high
infant mortality rates. Four intervention strategies and technologies recom-
mended by UNICEF are described. They are referred to as GOBI: growth
monitoring, oral rehydration therapy, breast feeding, and immunization.

The connection ofthe GOBI approach with education, attitudes, leadership,

social organization, social values, and costs, is pointed out. The impact of
GOBI as a strategy directed toward rapid. full-scale population penetration on
other programmes concerned with long-term health conditions, is considered.

Questions of the moral, demographic. and economic implications of GOBE

are raised. The importance of its immediate and future benefits is stressed.

Few involved in international high unemployment, and stagnating

development work continue to harbour il-
lusions that poverty will be significantly
reduced in the majority of developing
countries by the turn of the century. The
road to social and economic development
will continue to be blocked by chronic
debt burdens, declining terms of trade,
levels of aid. Economic and social gains
will continue, in many countries to be
eaten up by population growth. As such,
it would seem that the well-being and life
chances of hundreds of millions of
children living in poverty in the develop-
ing countries, is not going to improve
markedly in the near future.

lOr. Halpern is a Senior Research Associate at the High/Scope Educational Research Foundation, 600
River Street, Ypsilanti, Michigan 48197.
42 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
Nonetheless, in the past few years,
particular segments of the international
development community, led by UNICEF
and its executive director James Grant,
have been arguing that we now have
available the ingredients to achieve "a
child survival and development
revolution" (Grant, 1983). These in-
gredients include improved medical tech-
nologies -- oral rehydration therapy
(ORT) to stop and reverse the dehydra-
tion associated with diarrhea; hardier
vaccines, re-usable syringes. and better
cold storage techniques to make im-
munization against infectious diseases
more accessible. They include two par-
ticular health self-care practices -- breast
feeding, and monitoring of young
children's growth using growth charts.
Finally, these ingredients inc I ude new
approaches to dissemination of the new
medical technologies; and improved
strategies for communicating the impor-
tance of breast feeding, growth monitor-
ing, and other "self-care" practices (such
as hand washing).
What are the prospects for this in-
cipient revolution? Can children's life
chances be improved without correspond-
ing improvements in the resources their
parents and communities can command?
Can women -- who. as we will see, are the
key figures in the child survival and
development revolution -- be encouraged
to adopt technologies and behaviours that
may not be consonant with other aspects
of their daily lives? To what extent do the
ingredients of this revolution address the
quality of life of the nine out of ten
children who survive infancy in the
developing countries? In this paper. [ ex-
amine the Child Survival and Develop-
ment Revolution in light of these and re-
lated questions.
Dimensions of the Child Survival
and Development Problem
Child Survival. Because the notion
of millions of unnecessary infant and
child deaths per year is so morally un-
acceptable. the child survival and
development problem has been framed by
the challenge of reducing infant mor-
tality. After declining steadily for two
decades, the infant mortality rate in the
developing countries now hovers at 120
per 1000 live births 2 The comparable
rate for the United States is 12 per 1000
live births. Assuming that the U.S. rate.
not the best among industrialized
countries. is a reasonable standard, that
means at least 15 million unnecessary in-
fant and early childhood deaths a year in
the developing countries.
The immediate cause of mortality in
infants and young children in the
developing countries is almost invariably
the interaction of two or more of the fol-
lowing problems: dehydration associated
with diarrhea; pneumonia or other lower
respiratory infections; and complications
associated with one of six immunizable
diseases (measles. tetanus, pertussis.
diptheria, poliomyelitis, tuberculosis).
?
"The average infant mortality rate for the
developing countries masks WIde intra- and inter-
regional dispanties. For example. While only two
countries in the western hemisphere t Harti and
Bolivia) have Infant mortality rates above 100 per
1000 live births. fully four fifths of Africa does. At
any particular level of societal wealth t i.e., per
capita Income). infant mortality as an indicator is
particularly sensitive to distributive issues. Thus
China has reportedly reduced infant morality to 50
per 1000 live births. despite one of the lowest per
capita Incomes In the world. By contrast, Oman,
WIth a per capita GNP of $6.000, has one of the
highest infant mortality rates in the world at 120
per 1000 live births.
HALPERN
Malnutrition is an underlying con-
tributor to the majority of infant and
child deaths in the developing countries.
A number of social factors underlie
the immediate biomedical causes of the
high infant mortality rates in the
developing countries. These range from
women's status to parental belief systems
and behaviours, from environmental con-
tamination to broader historical patterns
of social resource distribution.
Maternal Education. The variable
most strongly correlated with infant mor-
tality, as well as morbidity, is maternal
education. The poorer the community,
the more important modest differentials
in maternal education are to child sur-
vival (Mosley, 1984). Some 50 per cent of
women currently of childbearing age in
the developing countries are illiterate.
and some 35 per cent of the next
childbearing generation, girls currently
aged 6 to 11, are not enrolled in primary
school. Of the 65 per cent enrolled, half
may not complete primary school
(Newland, 1981; Coombs, 1985). Lack of
maternal education will likely influence
child survival for years to come.
Mothers with at least some formal
education are better able to protect their
children against the threats posed by in-
adequate living conditions. Relatively
more educated women display greater
selectivity in using traditional and
modern ideas and practices (for example.
greater willingness to discard tradi-
tional, often harmful. weaning practices);
greater understanding of, and willing-
ness to, invest in preventive health
practices/services; more etTective alloca-
tion of time to different kinds of activities
(employment, household production.
health); and better judgement of the
seriousness of a child's illness (Newland.
43
1981; Ware, 1984). There is evidence
that women with more education marry
later, and have less closely-spaced births
(Harkavy, 1985). Both of these reduce
eventual completed family size 3 .
Demographic Factors. Family size,
birth spacing, and a particular child's
birth order are themselves strongly
correlated with child mortality and mor-
bidity in the developing countries. Birth
order and birth spacing are crucial to dif-
ferent children in different ways. The
growing fetus of a mother nutritionally
depleted from too many births too close
together is at unusually high risk of in-
trauterine growth retardation and infec-
tion. The most recent born is likely to be
abruptly, and perhaps prematurely,
weaned if a mother becomes pregnant
again. Abrupt weaning can lead to a se-
quence of periods of growth deceleration
and growth arrests, associated with diar-
rheas and respiratory infections (Mata,
1984).
Beyond infancy, later born children
in large families -- especially children
fourth or higher in the birth order -- are
more likely to be malnourished and less
likely to be selected by their parents to
attend primary school (Pollitt. 1984).
These children experience the double
jeopardy of being especially likely to be
born in a biologically vulnerable con-
3The relationship between female education
and other mediators of child survival and well-
being is apparently not totally straightforward.
For some of these other variables, such as fertility
behaviour and breast feeding. there seems in some
studies to be a negative relationship for 1 to 4
years of schooling, With family size increasing and
breast feeding rates decreaseing. Achievement of
literacy, or completion of at least a 4 year primary
cycle, appears to be crucial to benefits found
(Birdsall. 1980 I.
44 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
dition, and having to compete for scarce
family resources with more productive
family members.
Total completed family size is itself
a predictor of child survival and mor-
bidity. Expectations of the need to
replace children who die in early
childhood, partly, but do not fully, ex-
plain why the average completed family
size in the developing countries still ap-
proaches 5 children per family. The need
for social security in old age also in-
fluences family planning decisions. So do
cultural and religious factors, notably the
degree to which women have control over
the timing and number of children.
Fertility decisions of families be-
come, at the macro-level, the population
"problem". Even though families in
many developing countries are deciding,
in some cases under government pres-
sure, to have fewer children, the current
large base of men and women of
reproductive age is projected to yield a
doubling of population in the developing
countries by the year 2025. from 3.5 to
about 7 billion people (McNamara, 1984).
This inevitable doubling of popula-
tion negates almost by definition, the
currently promoted notion that economic
growth can compensate for and even-
tually contain population growth
(Chandler, 1985). It cripples the notion,
promoted by many governments in the
1970's, that "development is the best
contraceptive." And it enormously com-
plicates the problem of integrating sub-
stantial portions of the population in
developing countries into distribution
networks for various social goods, includ-
ing the proposed child survival tech-
nologies.
Other Influences on Child Survival.
A variety of other social factors influence
child survival. We learn, for example,
that 75 per cent of the 214 million young
children in the highest infant mortality
rate countries (over 100 per 1000 live
births) and 50 per cent of the 105 million
young children in the high infant mor-
tality rate countries (60-100 per 1000 live
births) have no access to potable drinking
water (UNICEF, 1985). We learn that as
many as half the young children in the
developing countries live in grossly in-
adequate housing, and perhaps 75 per
cent lack access to adequate human
waste disposal services (Chandler, 1984).
More indirectly, a host of variables
shape parental behaviours and environ-
mental conditions in ways relevant to
child survival. Land tenure patterns and
agricultural marketing policies affect not
ony aggregate food supply, but distribu-
tion of food. Rapid urbanization sends
millions of women far from home every
day to engage in ambulatory vending.
Many nations are forced to spend na-
tional income that should be invested in
social and economic development
programmes, on the service of enormous
debts to banks in the United States and
other industrialized countries.
Child Development
Malnutrition, recurrent infection,
high fertility rates, maternal illiteracy,
and the other problems documented
above, do not just affect the survival side
of the equation. They have devastating
consequences for child development, both
during the early childhood years and
beyond. Malnutrition and recurrent in-
fection reduce the amount of learning
time in the early years; parental
childrearing strategies focused on child
and family survival shape the goals of
available learning time.
HALPERN
Malnourished children -- nearly the
majority in many developing countries --
are less active, less able to concentrate on
learning activities, and less interested in
the environment, than are adequately
nourished peers (Pollitt & Thompson,
1977). They may be less socially attrac-
tive to caregivers, further reducing their
ability to evoke positive and stimulating
responses from those caregivers and the
broader social environment. In addition
to being chronically malnourished, the
young child in a typical developing
country my be ill 16 to 20 weeks a year
(UNICEF, 1985). In many contries, mal-
nutrition and recurrent infection cause
the average child to miss as much as a
third of scheduled school days (Berg,
1981).
Under conditions of high infant mor-
tality, parents will presumably focus
their childrearing energies on assuring
the physical survival of their young
children, and on the promotion of
children's capacity to make an immediate
economic contribution to family well-
being (LeVine, 1977; Pollitt, 1984).
Translated into psychological terms, this
will mean a relative de-emphasis on ex-
plicit literacy-nurturing activities, espe-
cially when parents themselves are il-
literate.
For example, parents under highly
stressful environmental conditions and
in a context of minimal literacy, may
promote primarily concrete use of lan-
guage and concrete classification skills in
their young children. Schooling, an im-
portant path to improved life chances for
those children, demands relatively more
abstract use of language and classifica-
tion skills based on more abstract
qualities of objects (Haglund, 1982).
In sum, the child survival and
45
development problem is a multifaceted
and synergistic one. Each problem ex-
aggerates the effects of the other
problem. The necessary focus on day to
day survival inadvertantly undermines
the less immediate, but equally impor-
tant, need to invest in those activities
that will bear fruit only in the future.
The Child Survival and
Development Revolution:
Elements of a Response
Underlying the web of problems con-
fronting most young families in the
developing countries, is the telescoped
time frame in which problem definition
and solution are taking place in the child
survival debate. It took the United
States 80 years to move from an infant
mortality rate of 120 per 1000 live births
to a rate of 12 per 1000 live births. The
developing countries are under pressure
to make that transition in the course of a
generation. As Mills and Thomas note
(1984, p.z),
Developing countries face
the massive task of coping
simultaneously with all the
health problems that more
developed countries have
tackled gradually over the last
two hundred years.
They have before them the full array
of intervention choices and technologies
used by developed countries, but not the
resources or infrastructure to use them
all at once.
GOBI: The Heart of the Child
Survival and Development
Revolution
Among the array of intervention
46 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
choices and technologies available to
developing countries, four have been
promoted by UNICEF as the core of the
child survival and development revolu-
tion. These four, now widely referred to
by the acronym GOBI, are growth
monitoring, oral rehydration therapy,
breast feeding, and immunization.
The goal of growth monitoring is to
increase mothers' awareness of their
young children's nutritional and health
status. Mothers or community health
workers would use growth charts to
record regularly (e.g., monthly) young
children's weight. Enough measure-
ments would yield growth curves that in-
dicate actual in relation to expected
weight gain, and could warn a mother of
growth problems in a child.
The purpose of oral rehydration
therapy is to prevent the dehydration due
to diarrhea that in its extreme can lead to
an escalating biological crisis ending in
death. Oral rehydration therapy (aRT)
is based on the discovery some 20 years
ago, that glucose, added to a mixture of
salt and water (in correct proportions)
can significantly increase the body's ab-
sorption of the latter ingredients in cases
of diarrhea. (Sucrose, common table
sugar, has less absorptive effects, but is
more readily available in the home.)
As with growth monitoring, promot-
ing the use of aRT is primarily an educa-
tional issue -- to encourage mothers to
view continued feeding, rather than with-
holding, of both the aRT mixture and
solid nutrients as the appropriate
response to diarrhea in a child.
The child survival-related purposes
of breast feeding and immunization are
self-evident. The immunological, nutri-
tional, hygenic, and contraceptive
benefits of breast feeding, especially in
developing countries, are well-
documented (Huffman & Lamphere,
1984). Likewise, the rationale for in-
creasing rates of immunization against
neonatal tetanus, pertussis, measles, dip-
theria, poliomyelitis, and tuberculosis is
inherent in the demonstrated effec-
tivenss of immunization. At the present
time less than 20 per cent of children in
the developing contries are adequately
immunized against these six diseases.
Why the Particular Elements of
GOBI?
Given the seemingly endless list of
interconnected threats to children's well-
being in the developing countries, why
were these four elements chosen as the
core of a strategy to reduce infant mor-
tality and morbidity? One reason is
front-end cost. For example, while a
sanitary water supply could reduce the
incidence of diarrhea in the developing
countries by half, it would take an inter-
national investment of $10 billion a year
for the forseeable future, to assure that
supply (Chandler, 1984). Oral rehydra-
tion packets, though a curative technol-
ogy, cost pennies a piece. The whole
GOBI package has been estimated to cost
less than $10 a year per child (in the ag-
gregate, a $2 to $3 billion annual global
investment).
A second rationale frequently of-
fered for the GOBI approach is
simplicity. Improving water supply in-
volves development of reliable, simple
pumps (engineering), careful well place-
ment (survey), a concrete apron to keep
the well free from bacterially infected
water (construction), and educating the
community to proper usage and care.
The GOBI technologies and practices
seem to require less, principally under-
HALPERN
standing, willingness, and in the cases of
ORT and immunization, innovative
"population penetration" strategies.
A third reason for the choice of the
GOBI elements is the directness and
known efficacy of their impact on child
mortality and morbidity. For example,
timely immunization against measles is
over 90 per cent effective in preventing a
disease associated with 2 million child
deaths a year in the developing countries.
Even though ORT is being used by only
10 per cent of the developing world's
families, it is reported to have saved half
a million children's lives in a recent 12
month period (UNICEF, 1985).
The GOBI Strategy: Basic Con-
cerns and Implementation
Challenges.
In spite of the seeming obvious
potential of the GOBI strategy, there is
far from unanimous agreement among
experts and observers, not to mention
third world families, that it will be as
inexpensive, as simple to implement and
as effective, as promised. On the one
hand, the GOBI strategy has been
criticized for being too narrow in focus.
As Grant and colleagues themselves
noted in UNICEF's 1980/81 "State of the
World's Children" report, "Development
does not come in individually wrapped
parcels." On the other hand, it has been
criticized for promising too much, for
glossing over some of the formidable im-
plementation problems inherent in its
chosen technologies and practices. In
this light, the GOBI strategy will only
represent a "breakthrough" to the extent
that the educational, motivational and
distributional problems inherent in its
technologies and proposed practices are
successfully addressed.
47
Improved Child Survival:
Demand or Supply?
The historical experience with im-
provements in maternal and child health
-- based on evidence from the industrial-
ized countries -- suggests that such im-
provements are closely linked to im-
provements in broader living conditions
(Fuchs, 1974). Yet underlying the GOBI
strategy is the assumption that, given the
development of medical technologies,
preventive health knowledge, and social
intervention strategies not available
when today's industrialized countries
were developing, children's health and
well-being can be improved in the ab-
sence of improved overall living con-
ditions.
One key to the success of this "de-
coupling" will be the ability of govern-
ments and social institutions to
deliberately stimulate the demand for
improved health conditions that would
grow more gradually with improved
living conditions 4. According to the
promoters of GOBI, demand for the tech-
nologies and knowledge that would
prevent death and reduce illness in
children, is not absent in the world's
poorest families, only latent. Such
demand "is covered over" by a pervasive
sense that one's children's fate is "in the
hands of the devas or in the lap of the
gods."
4Before the dominant political and social in-
stitutions in a country can be recruited to stimu-
late bottom-up demand for the GOBI technologies
and practices, they themselves must be convinced
to put their prestige at the service of the child
survival and development revolution. James
Grant, going personally and directly to heads of
state and international religious leaders, has been
remarkably successful in working at this level to
date.
48 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
UNICEF staff argue that families
will accept and utilize the GOBI tech-
nologies and practices if GOBI is
"promoted" by those whose word is or-
dinarily trusted -- religious leaders, in-
digenous doctors, teachers and the media
(Vittachi, 1984). Moreover, the GOBI
technologies and practices are designed
to be used (or at least managed) by
parents themselves. And, to differing
degrees, they yield immediate, visible
results. Together, these factors can alter
parents' perceptions that they have little
ability to influence their children's fate.
Nonetheless, some observers argue
that the GOBI strategy is simply too
supply-oriented; that it underemphasizes
the "social constraints to demand for and
use of' the GOBI technologies and prac-
tices (Mosley, 1984, pAl. In other words.
the same factors that contribute to high
infant mortality rates would constrain
families' use of these new technologies to
reduce those rates. Successful implemen-
tation of GOBI will depend in some
measure on alteration of those be-
haviours, beliefs, family priorities and
broader social values that are most
closely linked to improved living con-
ditions.
To take one example, following com-
plex immunization schedules neces-
sitates a significant measure of motiva-
tion <based in part, on an understanding
of preventive principles). and the ability
to plan and control the use of time. These
schedules include 2 shots during preg-
nancy, to prevent neonatal tetanus. a
series of 3 DPT injections and 2 or 3 doses
of polio vaccine, all during the first year
of life, a tuberculosis shot at birth and a
measles shot at about 9 months. Com-
pleteness of a series, population
coverage, and timing of administration
all have significant effects on
mortality/disability aversion. The cir-
cular problem is that it is difficult for a
population to see the effectiveness of a
vaccine, for example for measles, until a
large number of children in a very nar-
row age range are immunized; yet it is
hard to get that large number immunized
unless the whole population sees the
value of immunization.
Immunization is, in relative terms,
the most passive of the GOBI
technologies/practices. Active medical
outreach, typically in the form of nation-
wide campaigns and immunization days,
has been demonstrated in a number of
countries to overcome lack of under-
standing of prevention principles, lack of
time to bring a child to a health post, and
so on (UNICEF, 1985). Use of oral
rehydration therapy, the other medical
technology involved, presents a greater
challenge in terms of effective demand.
One of the most experienced inter-
national managers of ORT programmes
has argued that it is not necessary "to
change the mother's idea of what causes
diarrhea, or even the fact that it is poten-
tially dangerous" (Rohde, 1983, p.55). It
is only necessary to get the message
across -- pervasively and repetitively --
that drinking and feeding are the correct
response to dehydration. But this view is
not universally accepted.
As UNICEF staff themselves note
(UNICEF, 1984, p.39),
Several times ORT cam-
paigns have foundered because
mothers who knew how to make
an effective oral rehydration
mixture did not have the con-
fidence to use it when the time
came.
Oral rehydration therapy can in-
HALPERN
crease stooling, even cause vomiting, in
the first 12-36 hours it is used; so even
mothers who try it may not stick with it
until the diarrhea diminishes, unless
they are very confident of its benefits.
Under some circumstances, diarrhea is
so routine an occurrence that it is dif-
ficult to convince a mother than her child
is in a potentially life-threatening situa-
tion.
The ability of a mother or lay health
worker to gauge whether a child is ex-
periencing a "falling off' from his or her
expected normal growth, and then decide
what to do in response, is a relatively
complicated process. Growth faltering
cannot be picked up by judgments at one
or two points in time, and when present
usually is not due just to malnutrition.
The use of growth charts as an aid in
diagnosing growth faltering requires not
only accurate weighing and recording,
but regular compliance with the weigh-
ing regimen, and interpretation based on
knowledge of likely causes at work.
Marketing Survival
The argument that we now have the
ingredients for a child survival and
development revolution is based not only
on the availability and efficacy of the
GOBI elements, but on the assumption
that social organization and social
mobilization strategies in the developing
countries have improved sufficiently to
get those elements out to and used by per-
haps 100 to 200 million families. Im-
proved social organization includes
human service infrastructure - health
posts, schools, community centers: mass
media, especially radio; trade unions,
religious organizations, and civic or-
ganizations; and, ironically, distribution
networks for commercial goods. such as
Coca-Cola.
49
These social agencies would be
mobilized on behalf of GOBI through a
"social marketing" strategy, what
UNICEF has described as "marketing
survival." For example, market research
techniques have been used in Brazil to
discover what kind of breast feeding
promotion message women are most
receptive to. That message is then
promoted through a multifaceted adver-
tising campaign. In some countries, ex-
isting retail distribution networks have
been used to sell packets of oral rehydra-
tion ingredients. In Colombia, priests
performing baptisms reportedly
routinely remind mothers about vac-
cinating their infants (New York Times,
October 20, 1985).
Each of the social agencies poten-
tially involved has its own strengths, and
it is attractive to visualize the involve-
ment of so many segments of the com-
munity in a common programme of ac-
tion for young children. The involvement
of a variety of social agencies has already
stimlulated some innovative
programmes. For example, primary
school children have been taught the
procedures for using oral rehydration
therapy, and then encouraged to share
this knowledge with their parents (Cole-
King, 19831.
Organizational Challenges
Even assuming creative and flexible
uses of different social agencies,
developers and managers of GOBI
programmes will not be able to escape the
host of strategic dilemmas common to
other primary health care programmes.
These include: role definition for front-
line workers; choice of message-promoter
and local implementing agency; building
capacity for ongoing monitoring of
progress, and, if necessary, redirection of
50 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
strategy; and maintaining quality as
small-scale efforts are expanded.
The ubiquitous community health
worker will have a crucial role in educa-
tion regarding the use of "ORT, in
village/neighbourhood management of
growth recording for growth monitoring,
and in breast feeding and weaning educa-
tion. Whether there will be separate
ORT or growth monitoring or breast feed-
ing workers, or whether these concerns
are integrated with other educational
and patient care concerns (e.g .. family
planning, disease management, environ-
mental sanitation) are crucial decisions.
Health workers' traditional purpose is to
participate in a long-term process of com-
munity health improvement. We do not
yet know if the GOBI strategy, focused on
rapid. full-scale population penetration,
to achieve immediately visible results,
will undermine the necessary patient,
long-term incremental work underlying
fundamental improvements in public
health conditions.
Evidence from a variety of social
programmes in developing countries,
suggests that the particular mix of social
agencies employed in any discrete
programme will be an important
mediator of success (Korten, 1980). As a
rule, there must be enough variety to
support the differentiated strategy that
will be necessary to reach different social
groups with technologies and educational
messages. For example, even within
small, rural villages, stratification (e.g.,
between landed and landless) can create
profound differences in needs, percep-
tions and interests. A single community-
based organization might not have the
credibility, capacity, or leadership to
bridge these differences (Korten, 1980).
Further, over-reliance on existing village
leadership can strengthen the hand of
those who are responsible for much of the
inequality in a village (Berg, 1981).
What About the Survivors?
In all the debate that has occurred
about the child survival and development
revolution, there has been little discus-
sion about its potential to improve the
quality of life of children who, due to
GOBI or otherwise, survive infancy in
the developing countries. Even with cur-
rent unconscionably high infant mor-
tality rates, 9 out of 10 children survive
infancy in the developing countries. How
might GOBI affect their lives. and more
generally how might it influence other
social action on behalf of children and
their families?
At least some observers view the
likelihood of additional survivors -- in the
absence of social improvement on other
fronts -- as nothing more than an added
demographic burden, likely to lower the
quality of life of those who would have
survived anyway. As Chandler (1985,
p.6) notes,
Some even question the
morality of providing food, an-
tibiotics, inoculations, oral
rehydration, and other effective
measures against death, with-
out also providing tools for
agricultural productivity,
education, and birth control.
There are three strong arguments
against such logic. One is moral: there
simply is no excuse for letting prevent-
able child deaths occur. The second is
demographic: while in the short term
there is not a one-to-one correspondence
between child deaths averted and fewer
child births,
HALPERN
In the long run, as more
children survive, parents will
want fewer children in order to
provide them with better nur-
ture and education. (Harkavy,
1985, p.19)
The third is economic: healthier
children should be more productive, in
the present and the future, reducing
"needed" family size and increasing ag-
gregate societal ability to support popula-
tion growth.
Nonetheless, there is a least some
danger that the child survival and
development revolution will come to
define for many third world governments
and international donors, the whole early
childhood problem. Even the strongest
promoters of this "revolution" would not
argue that it addresses root causes of un-
necessary child mortality and morbidity
in the developing countries. In this light,
if the social determinants of child mor-
tality and morbidity discussed earlier in
this paper are not addressed as aggres-
sively as the more immediate biomedical
determinants, then we will have to con-
tinue to promote GOBI anew each
generation.
Finally, there is some danger that
an overriding focus on child survival will
inadvertantly undermine attention to
problems of child development. It is
sometimes forgotten that the conditions
that constitute such an extraordinary
threat to children's physical well-being in
the developing countries, also act to im-
pair psychosocial well-being.
While it is true that children's
development is ultimately adaptive, the
skills and qualities that contribute to
success in the immediate physical and so-
cial environment may not be the same as
51
those that will be required for success in
school, and ultimately in whatever
labour market exists. In this light, the
child survival and development revolu-
tion cannot afford to delay attention to
those strategies that hold promise for im-
proving child development and thus al-
tering children's likely futures.
On va discuter la probleme de survivance
et la developpement d'enfant et Ie defin
de reduire la rnortalite d'enfant dans les
pays developpent,
De plus, on va examiner les causes
bio-medicalles avec les determinations
sociales de la mortalite d'enfant.
UNICEF se recommende quatre
strategies et technologies d'intervention:
controller la croissance; allaitement
maternelle; la therapia orale de la
dehydration; et immunization (GOBI en
l'acronyme anglaisel.
Le lien entre les idees de GOBI, les
idees d'education, d'attitudes, de direc-
tion de l'organization, les valeurs sociales
et les couts enconomiques sont indique,
On disc ute l'impact de GOBI sur les
autres programmes de la sante publique.
Les questions de l'implications
morales, demographiques, et
economiques sont examine.
L'importance de l'advantage immediate
et dans l'avenir est traite.
Este articulo se refiere al problema de la
supervivencia y el desarrollo del nino asi
como al desafio de reducir la mortalidad
infantil en los paises en desarrollo.
52 A CHILD SURVIVAL AND DEVELOPMENT REVOLUTION?
Se analizan las causas biomedicas y
los factores sociales determinantes que
acompafian las altas tasas de mortalidad
infantil.
Se describen cuatro estrategias de
intervencion y tecnologias recomendadas
por UNICEF: Estas estrategias, con-
ocidas como GOBI (segun la sigla
inglesa), son: vigilancia del desarrollo,
terapia de rehidratacion oral, lactancia
materna e immunizacion.
Se sefiala la importancia de GOBI en
relacion con la educacion, actitudes,
liderazgo, organizacion social, valores
sociales y costo de programas. Se discute
el impacto de GOBI como una estrategia
dirigida hacia una rapida integracion de
la poblacion en gran escala en otros
programas centrados en mejorar las con-
diciones de salud a largo plazo.
Se analizan aspectos del GOBI
relacionados con sus implicaciones
morales, dernograficas y economicas.
Se enfatiza la importancia tanto de
sus beneficios inmediatos como aquellos
a largo plazo.
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