Underweight the main cause of ill-health; five causes account for 28% of all DALYs.

News Underweight the main cause of ill-health; five causes account for 28% of all DALYs Childhood and maternal underweight, unsafe sex, high blood pressure, tobac- co, and alcohol are the five main causes of today’s global burden of disease, in that order, of 25 health risks chosen for study by the Comparative Risk Assess- ment Collaborating Group, an interna- tional team whose research forms the basis for this year’sWorldHealth Report (see WHO News). According to the study, these five causes account for 28% of total dis- ability-adjusted life years (DALYs) lost to ill-heath each year. Childhood and maternal underweight causes 138 mil- lion DALYs (9.5% of total), unsafe sex 92 million (6.3%), high blood pressure 64 million (4.4%), tobacco 59 million (4.1%), and alcohol 58 million (4.0%). However, the ranking varies according to the state of development of countries. In the poorest regions of theworld the third, fourth and fifthmost important risk factors are unsafe water, sanitation, and hygiene; indoor smoke from solid fuels; and micronutrient deficiencies, while underweight and unsafe sex remain the first and second. Alcohol, tobacco, high blood pressure, and high cholesterol are major causes of disease burden in both developing and developed regions, the study concludes. This analysis of health by risks could not, however, include some important diseases, such as TB and malaria, which have multiple causes and influences varying from one group of people to another. Such diseases, say the re- searchers, are best suited to analysis of specific interventions tailored to specific settings, rather than to risk factor analysis. The Comparative Risk Assessment Collaborating Group consist of a team of over 140 experts from WHO and institutions predominantly in Australia, New Zealand, the United Kingdom and the United States, but also including institutions based in Canada, Chile, Mexico, South Africa, Spain, Sweden, and Switzerland, plus UNAIDS. Their study has been published in the Lancet and is available on the WWW (http:// image.thelancet.com/extras/ 02art9066web.pdf). n Robert Walgate, Bulletin Nepal’s childhoodmortality falls by half as vaccinations rise tenfold Nepal, one of Asia’s poorest countries, has been taking hard knocks in recent years, struggling with a Maoist rebellion since 1996, and facing the appalling slaughter of many of its royal family by one of its own members in June 2001. But a delighted Sarat Singh Bhandari, Nepalese Minister for Health, recently reported significant health improve- ments in the country. From 1980 to 2000 mortality in under five-year-olds fell by 55% (to 110 deaths of children 0–4 years old per 1000 births), said Bhandari; infant mortality has dropped by 33% (to 76 deaths per 1000 births) and fertility by 26% (to 4.7 children per woman). The population still managed to more than double — from 15 million in 1980 to 37 million in 2000 — but it would have risen further if it had not been for a steady rise in the use of modern contraceptives by married wo- men, from just 7% of such women in 1981 to 35% in 2001. The drop in child mortality is linked to the massive increase in the proportion of 12– 23 month-old Nepalese children fully immunized against diphtheria, pertussis and tetanus: a rise to 80% in the year 2000, from just 8% 20 years ago. These were some of the encoura- ging conclusions of Nepal’s new De- mographic and Health Survey, said the minister, speaking at the launching ce- remony for the Survey in Kathmandhu. Rebecca Rohrer, Director of the Health and Family Planning Unit of USAID, which funded the survey, said thatNepal has led the way in South Asia in improving demographic and health in- dicators in the last five years. Some professionals working in the health sector, however, are not so confident, at a time when all growth indicators in Nepal are pointing down- ward. ‘‘I feel the health service delivery system has worsened in the last five years,’’ claims Badri Raj Pandey, a senior health professional who has worked as the medical superintendent of Bir Hospital, the largest hospital in Nepal, and Chairman of Family Planning Association of Nepal (FPAN). There is certainly still a great deal to do. Pandey points out that most Nepalese women deliver their babies at home without any medical aid or birth attendant. And cultural taboos are so strongly rooted in the rural areas of far western Nepal that menstruating women and those delivering babies still have to live outside the home in a shed, and fend for themselves. The maternal mortality rate in Nepal was 539 per 100 000 live births in 1996, according to USAID figures. However Ms Pancha Kumari Man- andhar, a consultant at Health and Family Planning Unit of USAID, is confident Street theatre artists preparing for a family planning drama at Mainapokhar in Bardiya district, Nepal. Kh em ra jS hr es th a, JH U /C C P 988 Bulletin of the World Health Organization 2002, 80 (12) that the trends shown by the Demo- graphic and Health Survey are correct, that Nepal has really achieved a lot in the health and family planning sector over the years despite all the problems that the country has been facing, and that the trends are in the right direction. Credit is due in part, she says, to the massive public awareness of health issues created by information and com- munication campaigns, launched by the government and other health-related agencies, through the national radio network, regional community broad- casting and local FM stations, television as well as traditional and non-traditional channels of communication. Nepal is considered a leader in community broadcasting and FM networks in South Asia, she said. ‘‘But there are still strong cultural taboos. The results would have been better if all those women and children who wanted to take advantage of the health services could really travel freely from their homes to the health centres,’’ added Ms Manandhar. n Prakash Khanal, Kathmandu Africa’s largest measles vacci- nation campaign could reduce childhood mortality by 20% After years of declining immunization rates, a nationwide measles vaccination campaign in Kenya, the largest ever to be undertaken in Africa, was judged ‘‘very successful’’ by Minister of Public Health Sam Ongeri. ‘‘From a target population of 13.6 million the number immunized was 13.3 million, a record coverage of 98%’’ he said. In the year 2000 coverage was just 60%. Rudi Eggers, WHO Inter-Country Epidemiologist for Eastern Africa, told the Bulletin that ‘‘more than 85% coverage is needed to protect against a measles epidemic. We need to have a herd immunity effect’’. In other words, the few unimmunized people need to be far enough apart so that transmission cannot continue. ‘‘For measles this is quite a big task, as this is quite an infectious disease. So you actually need to reach very high coverage — 98% or so— to get that herd immunity. It seems that Kenya has reached that figure. We did a coverage survey after the campaign, to get some independent verification of that data’’ said Eggers. The biggest remaining uncertainty, however, is not the number vaccinated but the census — how many people there actually are in the country. And mopping up now needs to be done in areas that did not reach the target level. Measles in Kenya is still a severe disease. Some 10% of cases develop complications including convulsions, inner ear infections, pneumonia, diar- rhoea and inflammation of the brain. ‘‘Survivors are often left with lifelong disabilities including blindness and brain damage’’ said Ongeri. Yet over the last three years, Kenya had seen a fall in measles immunization coverage. It was estimated that 18 000 children were dying each year from measles in Kenya. Directly and indirectly, measles was contributing 20% of the mortality rate in children under five years of age. Nicholas Alipui, the UNICEF country representative, said that with the success of the campaign in Kenya, doors were opening for other African countries to undertake similar cam- paigns. ‘‘Measles has been and continues to be a highly contagious infectious disease throughout the world’’ said Alipuli. ‘‘UNICEF continues to stand behind the Ministry of Health, to use resources accrued from this campaign to strengthen routine vaccination in private and public health facilities.’’ With a concerted effort, he said, it would be possible for Kenya to have no measles deaths in a few years. The Kenyan Minstry of Health organized the vaccinations and ran this campaign, while WHO and UNICEF gave in-country support. The main funders were the USCenters forDisease Control, the UN Foundation and the American Red Cross. Eggers added, ‘‘A group called the Measles Initiative has solidified around those three funders, and now has US$ 20 million in the kitty to do more campaigns. We are planning for all of East Africa to be doing similar campaigns in due course’’. n Catherine Wanyama, Nairobi Reflectors could reduce road deaths ninefold, says Global Forum for Health Research 4500 secondary school pupils in Arusha, United Republic of Tanzania, a small tourist town in sight of Mounts Meru and Kilimanjaro, are to receive 5 cm- square plastic yellow reflectors to tie on their arms or pin on the backs of their clothes. These will help reduce acci- dents in which they are injured or killed by walking on the roads in the dark. The independent Global Forum for Health Research, which works to increase research on developing country issues, bought the US 60-cent reflectors ‘‘as a gesture’’ from the Danish makers ‘‘C you’’ — to coincide with Forum’s annual meeting in Arusha this November. ‘‘The children will get two reflectors each, one themselves and one for a sibling,’’ said a Forum spokesman. The Forum will seek investigators, and funding, to study their effect on deaths and injuries. In Denmark, studies have shown that reflectors reduce users’ risk of fatal accidents ninefold, according to the Forum but their effects in devel- oping country situations is unknown. While Kenya decided to vaccinate all age groups simultaneously, other countries such as the United Republic of Tanzania— here illustrated— chose to spread the vaccinations over two or three years. Kilosa district, Ruaha Catholic Clinic. W en dy St on e 989Bulletin of the World Health Organization 2002, 80 (12) News Every year, more than US$ 70 bil- lion is spent worldwide on health research by the public and private sectors, but only about 10% of this is devoted to 90% of the world’s health problems. The Global Forum refers to this as the ‘‘10/90 gap.’’ Samwell Nungu, consultant orthopaedic surgeon at Muhimbili Orthopaedic Institute, Dar es Salaam, is one African researcher who might be able to undertake work on the reflectors, given funding. He studies traffic accidents in Dar es Salaam, the capital of United Republic of Tanzania. He told the Bulletin that he sees 50 seriously injured under 12-year-old victims of road accidents victims every month. ‘‘The peak injury hours are in the evening, coming home from school, and in the late evening’’ said Nungu. Few streets have lights, and those are only in the city centre. ‘‘Reflectors will definitely contri- bute to the fight against accidents’’ said Nungu. But no comprehensive study had been done so far in United Republic of Tanzania on this age group of victims, looking carefully at the circumstances of the accident, said Nungu. ‘‘High-risk victims have to be identified and then targeted if we want to evaluate the results of any intervention measure’’. The reflectors should be made available to all children, Nungu believes — ‘‘not just schoolchildren, but also street kids from the town and the outskirts’’. According to WHO estimates road traffic injuries accounted for over 1.2 milliondeathsworldwide in the year 2000, amounting to 2.3% of all deaths. Many of thedeaths occur in young adults, and90% of the deaths occurred in the middle and low income countries, where death rates (21 and 24 deaths per 100 000 popula- tion, respectively) are approximately double the rates in high income countries (12 per 100 000 population). The objectives of The Global For- um’s meeting in Arusha, where it was to donate the reflectors, weremuchwider than traffic accidents, however. An independent, international foundation, established in 1998, and funded by the Rockefeller Foundation, WHO, the World Bank, and the governments of Canada, Denmark, Netherlands, Nor- way, Sweden and Switzerland, the Forum planned to ‘‘celebrate African Health research’’, showcasing the development of interventions by African institutions, their impact on the health of the African populations, particularly the poor, and their impact outside Africa. The Global Forum’s host partner for the meeting was the National Institute for Medical Research of Tanzania (NIMR). n Robert Walgate, Bulletin Kenya’s bus drivers go back to school Next door to the United Republic of Tanzania (see adjacent ‘‘reflectors’’ story), reckless drivers of Kenya’s ‘‘matatu’’ buses, who help make Kenya’s roads 20 times more dangerous than Britain’s, are to go back to driving school to improve their skills. ‘‘They are unsafe and reckless’’ passenger Musyoka Makau told BBC reporter Andrew Harding. ‘‘It’s a lack of responsibility’’. According to Harding ‘‘a morbid, macho culture’’ has prompted many matatu owners to paint names like ‘‘Chechnya,’’ ‘‘Aggression,’’ ‘‘Monica Lewinsky,’’ ‘‘Upsetter,’’ and ‘‘Why Drive When You Can Fly?’’ on the vehicles. Now with British funding special one day courses are being held for all of Kenya’s estimated 16 000 matatu drivers, Harding reported. ‘‘What is the brake for?’’ instructor Daniel Muchai asks a classroom full of youngmen. Silence ... Then a cautious volunteer suggests ‘‘to slow the vehicle?’’ ‘‘We’re trying to teach them the need to be responsible,’’ DicksonMbugua, who owns two matatus, and is also chairman of the Matatu Welfare Association, explaining to the BBC. ‘‘The course will teach them first aid too—and explain about the effects of driving when taking drink or drugs. We hope it will cut down the number of deaths on the roads.’’ RW One of Nairobi’s flamboyant matatu buses. C lif to n Ka ra ni -P ic tu re ne t 990 Bulletin of the World Health Organization 2002, 80 (12) News