Where Living Is Lethal

To experience childhood as Americans knew it a century ago, you don't have to travel very far. Just 700 miles from Miami, on Haiti's desolate Central Plateau, obesity and food allergies and attention deficit disorder are unheard of. In this part of the world, a healthy child is the one who escapes death from tetanus or tuberculosis--someone like 14-year-old Noula. When the boy's family carried him into Dr. Paul Farmer's frontier clinic in the village of Cange two years ago, he had a raging fever and a ballooning abscess on his back. Farmer's team saved his life by treating the TB and other infections that were devouring his spine. But they couldn't restore life to his legs--and they knew he wouldn't survive in his mountaintop settlement without them. So Noula lives in the clinic now. He wheels around behind the auxiliary nurses, coaxing moribund children to hang on, and he seems to feel he's the luckiest guy alive. When I met him last March, he had just been given a new wheelchair. His smile could have lit an office building.

In a sense, Noula is lucky. Kids like him still die in droves in Haiti--and Angola and Afghanistan and Bolivia and dozens of other poor countries. Worldwide, nearly 11 million children perish before their 5th birthdays every year. They don't die because science has yet to find treatments for their conditions. Most die for the lack of clean water, adequate nutrition and the most basic medical necessities--skilled birth attendants, 50-cent vaccines, antibiotics that were developed eight decades ago. "We know what to do," says Dr. Robert Black of Johns Hopkins University's Bloomberg School of Public Health. "We have interventions that are proven. What we haven't done is commit the resources needed to deliver them."

Children's lot is clearly improving by many measures. The overall death rate for kids younger than 5 has dropped by 30 percent since 1980. Some countries (Cuba, Brazil, Bangladesh) have made even greater strides. And bold initiatives by Bill Gates and other philanthropists have helped create a new sense of urgency and possibility. But obscene disparities persist. Kids born in South Asia and sub-Saharan Africa still die at 20 to 30 times the rate of kids in the industrialized world. In fact 90 percent of the world's childhood deaths --roughly 9.7 million a year--now occur in 42 developing countries. And 99 percent of the victims are poor.

What exactly is killing all these kids? Birth complications and neonatal infections are the biggest scourges, together killing 3.2 million children in the 42 hardest-hit countries each year. Diarrhea and pneumonia claim an additional 2.1 million lives each, followed by malaria, AIDS and measles. But none of these conditions kills at random. In a sense, every one of them is a symptom of poverty. Poor kids, wherever they live, encounter more than their share of health hazards--more crowding, more vermin, more contaminated water--and inadequate diets leave them doubly vulnerable to whatever hazards they confront. "More than half of the deaths in children can be attributed to undernutrition alone," says Black. "What finally kills the child may be pneumonia, but if the child were well nourished, he never would have developed it in the first place." The final blow is a lack of adequate health services. Kids in poor countries are not only more exposed and more susceptible to disease. Once sick, they often go untreated.

This dynamic plays out incessantly in the hills of central Haiti. Farmer started his clinic there in the mid-1980s, while studying medicine and anthropology at Harvard. His patients were landless peasants who'd been forced off their farms and onto the barren hillsides by a U.S.-sponsored hydroelectric-dam project. Thanks to his vision, tenacity and fund-raising acumen, the Clinique Bon Saveur is now a thriving community center with a school and a 104-bed hospital. Partners in Health, the relief group he founded with Harvard in 1987, now operates in seven countries. Traversing the shaded grounds at dawn, Farmer is mobbed by supplicants who have walked for days to get there and camped on the pavement once they arrive. "Feel my stomach," they plead. "Can you fix my hands?" "Please, look at my baby."

The medical staff works 16-hour days to avoid turning anyone away, and it has achieved astounding results. In the region served by Zanmi Lasante (Creole for Partners in Health), infant mortality now stands at one third Haiti's national rate. The interventions that make the biggest difference are often simple ones: sterile birth kits; antibiotics for typhoid; milk, zinc and vitamin A to combat malnutrition. Policy analysts estimate that these and other basic measures could save 6 million children a year--all for the price of a few aircraft carriers.

Unfortunately, the gap between possibilities and realities is growing ever wider. As World Bank health consultant Davidson Gwatkin observes, "The more you need health care, the less likely you are to receive it." Some 46 percent of children are still born without skilled attendants in the neediest countries. Fewer than half have access to potable water and only 5 percent of those who are at high risk of malaria sleep under insecticide-treated mosquito nets. Vaccination rates are actually falling throughout sub-Saharan Africa. In that region, according to UNICEF, the proportion of kids immunized against measles fell from 62 percent in 1990 to 50 percent in 1999, as government priorities shifted.

Political will is the key commodity. For all the talk of leaving no child behind, the United States has yet to commit more than a 10th of 1 percent of its gross domestic product to foreign health assistance. And as a global task force noted recently in The Lancet, U.S. development aid for child survival has declined in the past few years. Even within the United States, 12 million children still live in poverty, 9.2 million lack health insurance, and federal rules bar immigrant children from receiving public-health benefits until they've been here five years. "The consequences of this neglect are painful and expensive," says Irwin Redlener, president of the nonprofit Children's Health Fund and associate dean of Columbia University's Mailman School of Public Health. "We've made a mockery of our rhetoric. It turns out not to mean very much in terms of real dollars and services."

Dollars and services are important. But like many doctors who serve the poor, Farmer dreams of something more fundamental. The ultimate challenge is not just to manage the symptoms of poverty, he says, but to change the social arrangements that perpetuate it. His clinic is set up to handle 35,000 patients a year, but it took in nearly 200,000 destitute peasants in 2002--even as Haiti struggled to meet interest payments on foreign debts incurred by past dictators. His efforts may inspire awe, but as he is the first to admit, they are stopgaps.