(December 2002) According to the World Health Organization (WHO), around 300 million people worldwide suffer from malaria each year resulting in at least 1 million deaths. Malaria is endemic in 100 countries, a factor that places more than 40 percent of the world’s population at risk.1 Sixty percent of Cambodia’s landscape poses a malarial risk. One million Cambodians are infected with malaria each year. Of those infected, between 1.5 percent and 10 percent in some remote provinces, die.2 Efforts taken by Cambodia’s National Malaria Control Program (NMCP) have led to reductions of malaria outbreaks in the last decade. Between 1997 and 2001, the number of new malaria cases decreased by more than one third, from 15.05 cases per 1,000 in 1995 to 9.60 cases per 1,000 in 2001 (see Figure 1).3 Malaria remains one of the primary causes of mortality in Cambodia, however. Sustained efforts through local and national malaria control will be necessary to contain Cambodia’s malaria epidemic.
Malaria Incidence Rates in Cambodia, 1997-2001
Source: National Malaria Control Program, Cambodia.
Malaria is passed to humans by infected female mosquitoes. When the mosquito bites a person, it passes a parasite to the human bloodstream. The parasite is carried to a person’s liver and eventually multiplies. Another mosquito can then pick up the parasite by biting an infected person and can continue to spread the disease by biting another person.
Of the four human malaria strains, Plasmodium falciparum is the most common and deadly form, responsible for the vast majority of malaria death worldwide. In Cambodia, this parasite is responsible for the majority (88%) of malaria infections and deaths.4 Symptoms including fever, chills, headache, nausea, vomiting, diarrhea, and night-sweats occur 8 to 30 days after initial infection. Unlike other types of malaria, if not promptly treated Plasmodium falciparum may cause kidney failure, seizures, confusion, coma, and death. Prevention, early recognition of symptoms, and immediate treatment are key to curbing malaria-related deaths.
Malaria-infected areas tend to be those where mosquitoes can breed and survive easily such as wooded, shady areas and places where water and moist climate are common. In Cambodia, malaria tends to be found in the forest regions bordering Thailand, as well as in the rubber plantations found in the east and northwest. Urban and coastal areas are only slightly affected. These affected areas translate into a large number of Cambodians who are at risk of contracting malaria: An estimated 15 percent of the population is at medium to high risk of malaria infection.5 The populations most affected include forest inhabitants, migrant and border workers, pregnant women, and infants and children.
Though the population of the hilly and forested areas of Cambodia is small, malaria prevalence there is the highest in the country, ranging from about 15 percent to 40 percent in villages near or in forested areas, to 0 percent to 3 percent in the plains and surrounding rice fields. In Rotanak Kiri, Mondol Kiri, and Stueng Treng near the borders of Laos and Vietnam, forest populations account for 25 percent of recorded cases in the country but make up only 2 percent of the population.6 In these endemic regions, people are constantly infected with malaria. Over time, however, this continued exposure becomes a protective immunity against the parasite and its infection of the bloodstream.
Migrant and Border Workers
Migrant and border workers are exposed to malaria because their jobs — collecting wood, working on rubber plantations, and laboring in gem and gold mines — often bring them from areas of no or low malaria transmission to work in endemic areas. Unlike forest inhabitants who permanently live in endemic areas, these individuals have no built-up immunity to malaria. Immigrants and new settlers form a large nonimmune risk population — approximately 2 million people each year.7 Many migrant and border workers have limited access to health care and treatment, making malaria diagnosis and treatment difficult.
Pregnant women become more susceptible to malaria after their 14th week of pregnancy when any prior immunity to malaria breaks down.8 Malaria infections during pregnancy can cause anemia and lead to an increased risk of maternal death. Malaria in pregnancy also increases the risk of miscarriage and stillbirth. Babies born to mothers with malaria often have low birth weight, which endangers the survival and healthy development of newborns. Medical personnel advocate the use of antimalarial drugs throughout a pregnancy, as well as the use of insecticide-treated mosquito nets (ITNs) as part of prevention efforts.
Infants and Children
Children under age 5 make up 71 percent of all malaria deaths worldwide.9 A child’s most vulnerable period begins at 6 months of age when the mother’s protective immunity wears off and before the child has established his or her own robust immune system. In Cambodia, 9 percent of all malaria cases occur in children under age 5.10 Malaria is often fatal as an infected child’s condition may deteriorate quickly: Children can die within 48 hours after the first symptoms appear. For those who survive, repeated bouts of malaria hamper learning through missed school days and hinder a child’s physical and cognitive development. Children with malaria can, in most cases, be quickly and effectively treated with a course of inexpensive oral tablets called Malarine. Families and communities must be trained to recognize the symptoms of malaria and to seek treatment as quickly as possible.
Malaria can be prevented by avoiding contact with mosquitoes through the use of ITNs; eliminating mosquito breeding sites; and spraying households with insectide to repel or kill mosquitoes. In Cambodia, ITNs are an important cornerstone of government, nongovernmental organization (NGO), and donor malaria control strategies. The insecticide-impregnated nets repel mosquitoes and prevent bites that can lead to malaria. While ITN campaigns have been launched in various areas throughout Cambodia, universal coverage has yet to be achieved in high-risk areas. Increased distribution of ITNs and hammock nest targeted toward migrant populations are key to the long-term protection of vulnerable groups. Health education messages on malaria transmission tailored to communities’ social, cultural, and geographical settings and needs are also an important part of preventive measures.
Diagnosis and Treatment
As malaria can be fatal, early recognition of symptoms and immediate treatment are critical. Unfortunately, because malaria symptoms often resemble influenza or other febrile illnesses, individuals do not always seek medical advice. Thirty-two percent of rural children under 5 with malaria symptoms go without treatment or medical advice, compared to 23 percent of urban children.11
Cost and access often deter people from seeking diagnosis or treatment. Clinical diagnosis typically requires laboratory technology and skilled lab technicians to read the slides of blood under a microscope. Unfortunately, this level of technology and training is still rare in Cambodia. For this reason, a rapid diagnostic “dipstick” test has been introduced in Cambodia. This inexpensive test can be easily used in rural areas, increasing access to malaria testing.
Drug resistance complicates effective treatment of malaria in Cambodia. Cambodia has the largest number of drug-resistant forms of malaria in the world. There are many reasons for this: Mosquitoes are developing resistance to certain insecticides; environmental changes are creating new breeding sites; and people are commonly not finishing the full course of malaria medications or taking cheap, ineffective antimalarial drugs available on the market. Unlike other malaria-stricken countries, Cambodia cannot use the common malaria treatment Chloroquine, because it has strong drug resistance in northwest and southeast Cambodia. Mefloquine resistance has also been found in western provinces since 1995, but has not spread to other parts of the country. National drug policies have adapted to the changing resistance patterns, but the complexity of the situation has made implementation difficult. The recommended malaria treatment throughout much of Cambodia includes Mefloquine and Artemether.
Malaria treatment in Cambodia is further complicated by poor drug quality. In recent years, counterfeit drugs containing no active antimalarial substance have been found in private drug stores throughout the country.12 These fake drugs make it difficult to fight infection and result in increased malaria-related deaths. Government actions to produce antimalarial drugs in easy-to-identify packages and to restrict the selling of counterfeit drugs have assisted in efforts to improve drug quality. But more work is needed to ensure that individuals finish the full course of authentic malaria medications to prevent future strains of drug-resistant malaria.
The technology exists to prevent, monitor, diagnose, and treat malaria. Prevention campaigns must ensure that at-risk populations have access to ITNs and information on the signs and symptoms of malaria. Testing must be encouraged once symptoms appear and should be accessible and affordable to the general population. In addition, government efforts must focus on removing counterfeit drugs from the market and ensuring that malaria medications meet their prescribed potency. Sustained efforts through local and national malaria control programs are important to contain the malaria epidemic in Cambodia.
- The Global Fund to Fight AIDS, Tuberculosis & Malaria, Malaria: Key Facts, accessed online at www.globalfundatm.org/journalists/
fsheets/malaria.htm, on Aug. 15, 2002.
- National Malaria Center, Cambodia, “Malaria,” Vector Borne Disease Watch, accessed online at www.cnm.gov.kh/vbd.htm, on Aug. 1, 2002.
- Cambodian Ministry of Health, National Malaria Control Program (NMCP), “Malaria Situation in Cambodia: Strategies, Implementation, and Challenges, 2001,” public dissemination of NMCP data (Phnom Penh: NMCP, 2002).
- Cambodian Ministry of Health, NMCP, public dissemination of NMCP data (Phnom Penh: NMCP, 2002).
- Cambodian Ministry of Health, NMCP, public dissemination of NMCP data (Phnom Penh: NMCP, 2002).
- World Health Organization (WHO), Western Pacific Region, Malaria, Other Vectorborne and Parasitic Diseases, accessed online at www.wpro.who.int.themes_focuses/theme1/focus2/tlf2cambodia.asp, on July 29, 2002.
- European Commission (EC) Regional Malaria Control Program, MMF Issue 1, accessed online at www.mekong-malaria.org/mcis/
mmf3_27.htm, July 29, 2002.
- WHO, Maternal Mortality: A Global Factbook (Geneva: WHO, 1991): 9-10
- WHO, “Protecting Children From Malaria,” Roll Back Malaria Campaign, accessed online at www.rbm.who.int/newdesign2/children/
children.htm, Aug. 1, 2002.
- WHO, “Protecting Children From Malaria,” Roll Back Malaria Campaign.
- National Institute of Statistics (NIS), Directorate General for Health [Cambodia] and ORC Macro, Cambodia Demographic and Health Survey (CDHS) 2000 (Phnom Penh, Cambodia, and Calverton, Maryland: NIS Directorate General for Health and ORC Macro, 2001): 154-57.
- J. Rozendaal, D. Tith, and A. Thy, “Malaria Drug Quality in Cambodia, Summary of a Country Wide Investigation in November-December 1999,” in Malaria Control in Complex Emergencies: Cambodia, accessed online at www.lshtm.ac.uk/itd/dcvbu/malcon/Cambodia.pdf, on Aug. 1, 2002.
For More Information
Please contact the Department of Planning and Health Information, Ministry of Health, #151-153, Blvd Kampuchea Krom Ave., Phnom Penh, Cambodia
December 20, 2002
Population Reference Bureau
(December 2002) Despite major gains in child survival in the last 25 years, more than 10 million children around the world die each year before age 5, often from diseases and conditions that are preventable or easily treated. In some countries, more than 1 in 5 children dies before his or her fifth birthday. Many of those who survive childhood illnesses are unable to grow and develop to their full potential. In Cambodia, 1 in 8 children dies before his or her fifth birthday, and many suffer from diseases that are easily preventable through immunization, better nutrition, and proper sanitation.1 Effective programs to prevent and manage major illnesses in children promote healthy growth and development. Continued efforts to provide quality care will require an integrated approach, focusing on both preventive and curative elements to be implemented by families and communities, as well as by health facilities.
Early Childhood Mortality Rates
According to the 2000 Cambodia Demographic and Health Survey (CDHS), for every 1,000 babies born in Cambodia, 95 die in their first year, leading to one of the highest infant mortality rates in Southeast Asia (see Figure 1). Sadly, more than a third of these deaths occur in the first month of life. Another 33 children out of 1,000 die before their fifth birthdays. All together, 1 in 8 Cambodian children dies between birth and age 5.
Infant Mortality in Southeast Asia
Source: PRB, 2002 World Population Data Sheet.
Rural children, those born to mothers with no education, and those whose mothers did not receive assistance at delivery face even higher risks of death. Geographic disparities in child survival are also significant in Cambodia: Infant mortality is highest in Mondol Kiri/Rotanak Kiri (170 deaths per 1,00 live births) and lowest in Phnom Penh (38 deaths per 1,000 live births).2
Maternal nutrition problems such as anemia and malnutrition not only undermine the health of mothers, but also influence child health. Sixty-six percent of pregnant women in Cambodia are anemic. When mothers are sick or malnourished, their babies face a higher risk of disease and premature death.
Babies born to malnourished mothers are more likely to be too small (underweight). Babies born underweight die at significantly higher rates than those of normal weight and are at greater risk of infection, malnutrition, and long-term disabilities, including visual and hearing impairments, learning disabilities, and mental retardation. As actual birth weights were unavailable for most children, the 2000 CDHS asked mothers to estimate whether their children were born large, larger than average, average, smaller than average, or small. Children reported by their mothers to be smaller than average or small were two and one-half times more likely to have died before the age of 1 month than those reported to be average or larger.3
The timing of births has a powerful impact on child survival. Close spacing of births can harm infant health by forcing children to compete for nourishment and care. Children born close together have higher rates of malnutrition, develop more slowly, and are at increased risk of contracting and dying from childhood infectious diseases. In Cambodia, children born within two years of a preceding birth are almost three times (2.8) as likely to die within the first month of life (neonatal mortality) and more than twice (2.2) as likely to die in the first year of life (infant mortality) as children born after at least a four-year interval (see Figure 2).
Childhood Mortality in Cambodia by Birth Interval
Source: 2000 Cambodia Demographic and Health Survey.
Childhood immunization against the six standard vaccine-preventable diseases — polio, diphtheria, whooping cough (pertussis), tetanus, measles, and tuberculosis — has the potential to save an estimated 2.5 million children in developing countries every year. Immunization constitutes one of the most cost-effective health interventions. The World Health Organization (WHO) estimates that for every US$1 spent on vaccines, US$29 is saved in treatment and other costs.5 Despite the proven benefits of immunization, coverage in Cambodia remains low — only 40 percent of children are fully immunized against the above diseases.
Children in urban areas and those whose mothers attended at least secondary school are most likely to be fully immunized (see Figure 3). There are also significant variations by province. The proportion of children fully immunized ranges from a low of 12 percent in Kaoh Kong to a high of 63 percent in Bat Dambang/Krong Pailin.6
Full Immunization in Cambodia, Children Ages 12 Months to 23 Months
Source: 2000 Cambodia Demographic and Health Survey.
Three illnesses — malaria, diarrheal disease, and acute respiratory infection (ARI) — account for most of childhood morbidity and mortality. Diarrhea and ARI cause 80 percent to 90 percent of all deaths from communicable diseases in children under age 5 worldwide. Malaria causes more than 300 million episodes of acute illness and at least 1 million deaths annually in people of all ages. In Cambodia, children are frequently affected by these diseases.
In the CDHS, mothers reported that 19 percent of their children under 5 suffered from water diarrhea, and 5 percent from diarrhea with blood, in the two weeks preceding the survey. Young children ages 6 months to 23 months are more prone to diarrhea than children in other age groups. Dehydration as a result of diarrhea is a frequent cause of death in young children.
Many of these deaths could be prevented with oral rehydration therapy (ORT), in which the child is given a commercial or homemade water, sugar, and salt solution. The majority of children with diarrhea (61 percent) were treated with some kind of ORT, mainly homemade rice water (see Figure 4). Other treatments included increased fluids, pills or syrups, injections, or home remedies. Twelve percent of children with diarrhea did not receive any treatment.7 Efforts to control diarrhea in Cambodia must be both preventive and curative, based on multiple interventions including the promotion of breastfeeding, adequate complementary feeding, safe water supply, and safe sewage disposal, as well as ORT.
Oral Rehydration Therapy for Children Under Age 5 With Diarrhea, in Cambodia
Source: 2000 Cambodia Demographic and Health Survey.
The prevalence of fever is a primary manifestation of malaria and other acute infections in children. In Cambodia, mothers reported that 35 percent of their children under age 5 were ill with fever in the two weeks preceding the survey. Children ages 6 months to 23 months are more commonly sick with fever than children in other age groups. There is little variation in prevalence of fever by mothers’ education, residence, or sex of the child. Yet regional variations are marked, ranging from 4 percent of children in Prey Veang to 54 percent in Kampong Chhnang.
Of children who received treatment for their fever, 84 percent received pills (including antimalarial tablets) or syrup (see Figure 5). About 1 in 6 children received intravenous drip or injections, reflecting the severity of the illness. Seven percent received home remedies or other treatment for fever, and 1 in 10 children did not receive any treatment.8
Treatment of Children Under Age 5 With Fever, in Cambodia
Source: 2000 Cambodia Demographic and Health Survey.
Acute Respiratory Infection
ARI is a leading cause of mortality in young children, killing nearly 2 million children under age 5 in developing countries each year. According to the World Bank, ARIs account for between 30 percent and 50 percent of visits by children to health facilities and between 20 percent and 40 percent of children’s hospitalizations worldwide.9 Mothers reported that 20 percent of children under age 5 showed symptoms of ARI in the two weeks preceding the CDHS. In Cambodia, ARI prevalence varies by the age of the child. Children ages 6 months to 11 months are at greatest risk of developing ARI symptoms (27 percent) compared with other age groups. There are no differences in ARI prevalence by the sex of the child, mothers’ education, or place of residence. Regional variations persist: Prey Veaeng has the lowest (3 percent) and Kandal has the highest (32 percent) ARI prevalence among children under age 5.10
Interventions to treat ARI need not be expensive and can be administered at the local level. The U.S. Agency for International Development (USAID) estimates that simple ARI treatment with oral antibiotics, at a cost of 25 cents per dose, can be delivered at the community level to resolve most infant and childhood pneumonias.11
Programs to help children survive and lead healthier lives are straightforward and highly effective: birth spacing, immunization, nutrition, and sanitation. The economic benefits of such investments are well-documented, showing large-scale returns on investment in health and education and future savings on costs such as health care, remedial education, unemployment, and crime. Investing in children is investing in the future: Today’s children will be tomorrow’s educators, doctors, mothers, fathers, and leaders. Ensuring a healthy entry into adolescence and adulthood is fundamental to sustained development and prosperity in Cambodia.
- National Institute of Statistics (NIS), Directorate General for Health [Cambodia] and ORC Macro, Cambodia Demographic and Health Survey (CDHS) 2000 (Phnom Penh, Cambodia, and Calverton, Maryland: NIS Directorate General for Health and ORC Macro, 2001): 121.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 125.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 126.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 127.
- Global Alliance for Vaccines and Immunizations, The Impact of Immunization on Economic Development, accessed online at www.vaccinealliance.org/press/press_econ.html, on July 23, 2002.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 153.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 161.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 155-57.
- U.S. Agency for International Development (USAID), Global Health, Child Survival, accessed online at www.usaid.gov/pop_health/
cs/csari.htm, July 20, 2002.
- NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 155.
- USAID, Global Health, Child Survival.
For More Information
Please contact the Department of Planning and Health Information, Ministry of Health, #151-153, Blvd Kampuchea Krom Ave., Phnom Penh, Cambodia
Tel: (855 23) 425 368
December 3, 2002
Population Reference Bureau
(Décembre 2002) En dépit des acquis majeurs en termes de survie des enfants au cours des 25 dernières années, plus de 10 millions d’entre eux décèdent chaque année dans le monde avant l’âge de 5 ans, souvent à la suite de maladies et de conditions qui auraient pu être évitées ou traitées sans difficulté. Dans certains pays, plus d’un enfant sur cinq meurt avant son cinquième anniversaire. Et parmi ceux qui survivent les maladies infantiles, nombreux sont ceux sont la croissance et le développement sont affectés. Au Cambodge, un enfant sur huit meurt avant son cinquième anniversaire, et nombreux sont ceux qui sont atteints de maladies que les vaccins, une meilleure nutrition et une bonne hygiène permettraient d’éviter1. Grâce aux programmes efficaces de prévention et de traitement des principales maladies infantiles disponibles, il est possible d’encourager une croissance saine et un bon développement. La poursuite des efforts entrepris pour offrir des services de santé de qualité exige une approche intégrée, combinant des volets préventifs et curatifs et devant être mise en application tant au niveau des familles et des communautés qu’à celui des centres médicaux.
Taux de mortalité chez les très jeunes enfants
Selon l’enquête démographique et de santé réalisée en 2000 au Cambodge (EDS), sur 1.000 bébés nés au Cambodge, 95 meurent avant leur premier anniversaire, ce qui représente l’un des taux de mortalité infantile les plus élevés de l’Asie du Sud-Est (voir la figure 1), et plus d’un tiers de ces décès ont lieu au cours du premier mois de la vie de ces enfants. Par ailleurs, 33 enfants sur 1.000 meurent avant leur cinquième anniversaire. Au total, 1 petit Cambodgien sur 8 meurt avant d’atteindre l’âge de 5 ans.
Mortalité infantile en Asie du Sud-Est
Source : PRB, Fiche de données sur la population mondiale 2002.
Dans les régions rurales, les enfants nés de mères sans éducation et dont les mamans n’ont pas bénéficié d’aide à l’accouchement se trouvent dans une situation encore plus risquée. Les disparités géographiques en matière de survie des enfants sont également très importantes au Cambodge : les taux de mortalité infantile les plus élevés sont enregistrés à Mondol Kiri/Rotanak Kiri (170 décès pour 1.000 naissances vivantes) alors que les plus faibles sont ceux de Phnom Penh (38 décès pour 1.000 naissances vivantes)2.
Les problèmes de nutrition maternelle tels que l’anémie et la malnutrition affectent tant la santé des mères que celles de leur progéniture. Soixante-six pour cent des femmes enceintes au Cambodge souffrent d’anémie. Lorsque les mères sont malades ou mal nourries, leurs nourrissons sont d’autant plus à risque de maladie et de mort prématurée.
Les enfants nés de mères souffrant de malnutrition risquent davantage d’être trop petits (d’un poids inférieur à la normale). Et les bébés qui ont un poids trop faible à la naissance courent des risques beaucoup plus élevés de décès ou d’infection, de malnutrition et d’invalidités à long terme, telles que des problèmes de vue et d’ouïe, des difficultés d’apprentissage et des incapacités mentales. Les données exactes relatives aux poids à la naissance n’étant pas disponibles pour la plupart des enfants, l’EDSC 2000 a demandé aux mères d’estimer si à la naissance le poids de leurs enfants était élevé, supérieur à la moyenne, égal à la moyenne, inférieur à la moyenne ou faible. Les enfants déclarés par leurs mères comme d’un poids inférieur à la moyenne ou faible étaient deux fois et demi plus susceptibles de mourir avant l’âge d’un mois que ceux d’un poids égal ou supérieur à la moyenne3.
Espacement des naissances
L’espacement des naissances a un impact considérable sur la survie des enfants. En effet, les naissances rapprochées peuvent porter préjudice à la santé des nourrissons car elles forcent une concurrence entre enfants pour les soins et la nourriture. Les enfants nés à faibles intervalles enregistrent des taux plus élevés de malnutrition ; ils se développent plus lentement et sont plus susceptibles de contracter des maladies infantiles infectieuses et d’en mourir. Au Cambodge, les enfants nés deux ans ou moins après leur aîné sont presque trois fois plus susceptibles (2,8 fois) de mourir pendant leur premier mois d’existence (mortalité néonatale) et plus de deux fois (2,2 fois) plus susceptibles de mourir avant leur premier anniversaire (mortalité infantile) que les enfants nés à au moins quatre ans d’intervalle4 (voir la figure 2).
Mortalité infantile au Cambodge par intervalle entre les naissances
Source : Enquête démographique et de santé 2000 pour le Cambodge.
La vaccination des enfants contre les six maladies faisant traditionnellement l’objet de vaccins, à savoir la polio, la diphtérie, la coqueluche, le tétanos, la rougeole et la tuberculose, pourrait permettre de sauver environ 2,5 millions d’enfants chaque année dans les pays en développement. La vaccination représente l’une des interventions sanitaires les plus rentables. Selon l’Organisation mondiale de la Santé (OMS), chaque dollar dépensé en vaccins permet d’économiser 29 dollars de traitement et autres coûts5. Cependant, malgré les avantages prouvés de la vaccination, la couverture au Cambodge demeure médiocre : seuls 40 % des enfants sont entièrement vaccinés contre les maladies précitées.
Les enfants des zones urbaines et ceux dont les mères ont été au moins scolarisées jusqu’au secondaire sont plus susceptibles de recevoir l’ensemble de ces vaccins. Ces chiffres fluctuent de manière considérable d’une province à l’autre. Le pourcentage d’enfants entièrement vaccinés varie de 12 % seulement dans la province de Kaoh Kong à un maximum de 63 % dans celle de Bat Dambang/Krong Pailin6 (voir la figure 3).
Taux de vaccination complète au Cambodge pour les enfants âgés de 12 à 23 mois
Source : Enquête démographique et de santé 2000 pour le Cambodge.
Trois maladies – le paludisme, les maladies diarrhéiques et les infections respiratoires aiguës (IRA) – sont responsables de l’essentiel de la morbidité et de la mortalité infantiles. Les maladies diarrhéiques et les infections respiratoires aiguës provoquent 80 % à 90 % de tous les décès de maladies contagieuses chez les enfants de moins de 5 ans dans le monde entier. Le paludisme est responsable de plus de 3.000 millions de crises aiguës et d’au moins 1 million de décès chaque année chez les gens de tous les âges. Au Cambodge, les enfants sont fréquemment atteints de ces maladies.
Les mères interrogées dans le cadre de l’EDS pour le Cambodge ont déclaré que 19 % de leurs enfants de moins de 5 ans avaient souffert de diarrhée aqueuse, et 5 % de diarrhée avec du sang dans les selles au cours de deux semaines ayant précédé l’enquête. Les jeunes enfants âgés de 6 à 23 mois sont plus susceptibles de souffrir de diarrhée que les enfants des autres groupes d’âge. La déshydratation provoquée par la diarrhée est une cause fréquente de décès chez les jeunes enfants.
Un grand nombre de ces décès pourrait être évité grâce à une thérapie de réhydratation orale (TRO), où l’enfant reçoit une solution composée d’eau, de sucre et de sel, achetée dans le commerce ou préparée à la maison. La majorité des enfants souffrant de diarrhée (61 %) a fait l’objet d’un traitement basé sur une forme de TRO, le plus souvent une solution d’eau de riz préparée à la maison. Parmi les autres traitements figurent une augmentation de l’administration de liquides, des comprimés ou des sirops, des injections ou divers remèdes faits maison. Et 12 % des enfants souffrant de diarrhée n’ont bénéficié d’aucun traitement7. Les efforts déployés au Cambodge pour lutter contre la diarrhée doivent être à la fois préventifs et curatifs, et se fonder sur des interventions multiples, dont la promotion de l’allaitement, une alimentation complémentaire adéquate, l’accès à des ressources en eau sans danger et un bon système d’évacuation des eaux usées, en plus de la TRO.
La prévalence de la fièvre est l’une des manifestations primaires du paludisme et d’autres infections aiguës chez les enfants. Au Cambodge, les mères ont déclaré que 35 % de leurs enfants de moins de 5 ans avaient eu des accès de fièvre au cours de deux semaines précédant l’enquête. Les enfants âgés de 6 à 23 mois ont plus fréquemment de la fièvre que les enfants des autres groupes d’âge. Les variations en fonction du niveau d’éducation de la mère, du lieu de résidence ou du sexe de l’enfant sont minimes. Cependant, les variations régionales sont marquées, et fluctuent entre 4 % des enfants dans la région de Prey Veang et 54 % dans celle de Kampong Chhnang.
Parmi les enfants ayant bénéficié d’un traitement pour leur accès de fièvre, 84 % ont reçu des comprimés (dont des comprimés antipaludiques) ou du sirop (voir la figure 4). Environ un enfant sur six a bénéficié d’un traitement par perfusion ou par injection, ce qui reflète la gravité de l’infection. Sept pour cent des enfants ont reçu des remèdes faits maison ou d’autres traitements contre la fièvre, et un enfant sur dix n’a bénéficié d’aucun traitement8.
Traitement des enfants de moins de 5 ans atteints de fièvre au Cambodge
Source : Enquête démographique et de santé de 2000 au Cambodge.
Infections respiratoires aiguës
Les infections respiratoires aiguës sont la principale cause de mortalité chez les jeunes enfants, faisant près de 2 millions de victimes chaque année chez les moins de 5 ans des pays en développement. Selon la Banque mondiale, les infections respiratoires aiguës sont responsables de 30 % à 50 % des visites d’enfants dans les centres de santé et de 20 % à 40 % des hospitalisations d’enfants dans le monde entier9. Les mères ont déclaré que 20 % des enfants de moins de 5 ans présentaient des symptômes d’infections respiratoires aiguës dans les deux semaines précédant l’EDS pour le Cambodge. Au Cambodge, la prévalence des infections respiratoires aiguës varie avec l’âge des enfants. Les plus susceptibles de présenter des symptômes d’infections respiratoires aiguës sont ceux âgés de 6 à 11 mois (27 %). Il n’existe pas de différences en termes de prévalence des infections respiratoires aiguës en fonction du sexe de l’enfant, du niveau d’éducation de la mère ou du lieu de résidence, mais les variations régionales persistent : chez les enfants de moins de 5 ans, le taux de prévalence le plus faible de ces infections est enregistré dans la région de Prey Veaeng (3 %) et le plus élevé dans la région de Kandal (32 %)10.
Les interventions pour le traitement des infections respiratoires aiguës ne sont pas forcément coûteuses et elles peuvent être administrées au niveau local. Selon l’Agence des États-Unis pour le Développement international (USAID), un simple traitement avec des antibiotiques administrés par voie orale, moyennant 25 cents la dose, peut être fourni au niveau communautaire pour la plupart des pneumonies des nouveaux-nés et des enfants11.
Implications en termes de politique générale
Les programmes conçus pour aider les enfants à survivre et à vivre en meilleure santé sont simples et d’une grande efficacité : espacement des naissances, vaccination, nutrition et hygiène. Les avantages économiques de ces investissements ont été clairement établis et ils s’accompagnent de rendements importants dans les domaines de l’éducation et de la santé, et d’économies futures en termes de frais médicaux, de rééducation, de chômage et de criminalité. Un investissement dans les enfants est un investissement dans l’avenir : les enfants d’aujourd’hui seront les éducateurs, les médecins, les parents et les dirigeants de demain. La garantie d’une entrée solide dans l’adolescence et l’âge adulte est essentielle pour le développement durable et la prospérité du Cambodge.
- National Institute of Statistics (NIS), Directorate General for Health [Cambodge] et ORC Macro, Enquête démographique et de santé pour le Cambodge (CDHS) 2000 (Phnom Penh, Cambodge et Calverton, Maryland : NIS Directorate General for Health et ORC Macro, 2001) : 121.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 125.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 126.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 127.
- Global Alliance for Vaccines and Immunizations, The impact of immunization on economic development, consulté en ligne à l’adresse suivante : www.vaccinealliance.org/press/press_econ.html, le 23 juillet 2002.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 153.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 161.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 155-57.
- Agence des États-Unis pour le développement international (USAID), Global health, child survival, consulté en ligne à www.usaid.gov/pop_health/cs/csari.htm, le 20 juillet 2002.
- NIS, Directorate General for Health [Cambodge] et ORC Macro, CDHS 2000 : 155.
- USAID, Global health, child survival.
(December 2002) Stigma and discrimination remain a major fact of life for the estimated 29.4 million people with HIV in sub-Saharan Africa and for the more than 11 million children who have lost one or both parents to AIDS. Whether it is a worker afraid of being fired from a job or a woman terrified of losing her children and her home, well-founded fears exist for many with the virus. But despite agreement that stigma and discrimination must be overcome to turn the tide on the epidemic, communities and governments in Africa — as elsewhere — continue to struggle to protect people’s rights and dignity.
“The national AIDS plans of several African countries explicitly recognize the public health imperative underlying the promotion of human rights — an achievement in itself. Yet few governments actively promote or assist a rights agenda in relation to AIDS,” Mark Heywood of the AIDS Law Project at the University of Witwatersrand in Johannesburg has written in SAfAIDS News.
At the same time, the Joint United Nations Programme on HIV/AIDS (UNAIDS) notes that the real battle in Africa against AIDS takes place beyond the scope of governmental authority — in families and villages, where discrimination tends to be intensely personal. Reactions to the virus may be in the form of school children shunning others on the playground or in-laws spurning the widow of a son who died from an AIDS-related illness. A June 2001 meeting in Tanzania that sought to set a research agenda for stigma and HIV/AIDS in Africa described stigma within the family as being among the most subtle and debilitating forms of this problem and the hardest to address.
In the international arena, much has been done to frame HIV/AIDS as a major challenge to the human rights of those affected. Governments from around the world, including Africa, adopted a declaration at a special session of the UN General Assembly in June 2001 in New York that by 2003 they should enact, strengthen, or enforce measures to eliminate all forms of discrimination against infected people and other vulnerable groups. The right to nondiscrimination is also enshrined in a number of international instruments, including the Universal Declaration on Human Rights, the International Covenant on Economic, Social, and Cultural Rights, and the African Charter.
Nevertheless, negative reactions to people with HIV/AIDS persist, reducing the quality of life of millions. The stigma associated with HIV and AIDS causes some people to deny the risks of infection and avoid being tested, while others hide their infection, shun friends and family, and avoid seeking support and treatment. If their HIV status is revealed, those with the virus may be ostracized, refused treatment and care, or even face abuse and violence. The 1998 stoning to death of South African community volunteer Gugu Dlamini after she publicly disclosed her HIV status on World AIDS Day is one of the starkest examples of the negative attitudes related to AIDS. Such attitudes increase the epidemic’s impact on individuals, families, communities, and nations.
In South Africa, where one in nine people live with HIV, the AIDS Law Project reports that the main source of complaints over the years has involved employer discrimination and HIV testing that is performed without regard to confidentiality, people’s informed consent, or pre- and posttest counseling.
“Medical and employment malpractices are a main source of complaints and have remained fairly constant over the years,” notes the AIDS Law Project, a nongovernmental organization (NGO) that offers free legal advice and works to prevent discrimination against people with the virus. “It is interesting to note that a great number of cases involved the combination of irregular medical testing with that of employer discrimination.”
Employer discrimination may take many forms. The Southern African Development Community (SADC) has pointed out that some companies dismiss workers with the virus or hire only those believed to have a low risk of infection. In addition, many medical insurance schemes offered by companies have no HIV-related medical benefits, and some industries have even proposed overhauling their medical benefits schemes to get around anticipated HIV/AIDS expenditures. The Human Rights Monitor, produced by the Zimbabwe NGO Human Rights Forum, notes that some infected people have been denied promotion because it is felt they may die at any time.
Vulnerability to HIV and the related stigma and discrimination are linked to existing inequities and stereotypes, including racism, poverty, intolerance, and inequality between women and men. As such, the worst affected are already the most disadvantaged, whether on racial, gender, or economic grounds. In sexual relations between women and men, a woman’s safety may be compromised by a man’s opposition to condoms, the potential for abuse and violence in the relationship, and dependence on a male partner for economic or social support. At the same time, the woman may bear the blame for spreading the disease, regardless of the circumstances.
In sub-Saharan Africa, issues of gender as well as poverty, a lack of economic opportunities, limited access to education, information, and services, and traditional norms and practices significantly increase a woman’s vulnerability to HIV and lie at the root of her experience in trying to cope with the related stigma and discrimination.
Women make up the majority of adults (15-49 years old) in this region who live with HIV/AIDS — 17 million out of a total of 29.4 million, or 58 percent of all adults with HIV in sub-Saharan Africa, according to UNAIDS estimates for 2002. UNAIDS also reports that in some sub-Saharan countries, prevalence among teenage girls is five times higher than for teenage boys.
Studies show that ignorance related to HIV and AIDS is a major factor in the vulnerability of the region’s young women. Research by the United Nations Children’s Fund (UNICEF) found that among girls 15 to 19 years old, 70 percent in Somalia and more than 40 percent in Guinea Bissau and Sierra Leone had never heard of AIDS. However, a study in Zimbabwe by the United Nations Development Fund for Women (UNIFEM) indicated that even when women know about HIV/AIDS, “their economic dependence on men left them feeling ‘helpless’ to negotiate safe sex.”
The Swaziland Example
In Swaziland, a landlocked country of 1.1 million people, national government actions reflect a traditional society grappling to address an epidemic that had claimed one or both parents of an estimated 35,000 children under age 15 by the end of 2001.
In early 2000, the country’s parliament considered two motions that, though they were ultimately defeated, highlighted the prejudices and misconceptions facing people with HIV. One motion sought to create camps to quarantine those with the virus; another proposed sterilizing all infected residents. While these motions failed, the parliament did pass another to have miniskirts banned in schools, a move that appeared to distract from any real debate on prevention and education programs.
In 2001 the king announced a controversial five-year sex ban for women of marriageable age. Young women are expected to wear traditional tassels to show their virginity and are forbidden from wearing pants. This ruling is being promoted as an anti-AIDS move.
Urging greater openness and discussion of the rights of the Swazi people affected by the epidemic, a 2000 study sponsored by the United Nations Development Programme (UNDP) directly addressed these kinds of reactions.
“On a one-to-one basis, particularly at the domestic level, the reality is that people living with HIV/AIDS are stigmatized, discriminated against, and rejected,” according to the report Human Rights, Ethical Issues, and HIV/AIDS in Swaziland. Moreover, the study states, stigmatization and discrimination have contributed to the silence and denial about the HIV/AIDS epidemic in Swaziland “and has resulted in the epidemic being driven underground, contributing to the unprecedented spread of infection.”
The study shows that workers have been fired when their HIV status was discovered. It also noted, however, that many large companies are trying to address the epidemic “ethically” and to support sick employees.
Workplace policies and practices are guided by a 1998 Swaziland policy document on HIV/AIDS and the prevention and control of sexually transmitted infections (STIs). International guidelines, such as the International Labour Organization Code of Practice on HIV/AIDS, also play a role. The Swaziland policy document calls on the government to promote information and education programs to dispel myths and fears about HIV/AIDS and to promote the rights of people. However, no specific anti-discrimination laws have been instituted to protect those with the virus.
Likened to a “Switzerland” of Africa for its low regional and international profile, this kingdom of rolling hills and forests is tucked between Mozambique and South Africa and has a gross national per capita income of US$1,300 (compared with US$2,900 for South Africa), by World Bank estimates. A British protectorate until 1968 when it became independent, Swaziland’s largely homogeneous population comprises mainly Swazi people who speak Siswati and English.
Swaziland is a modern African country whose people have held steadfastly onto its traditions. The capital, Mbabane, has two gleaming, well-trafficked malls, while local merchants continue to sell their wares along the roadsides. The famous Umhlanga or “Reed Dance” festival is now being used by NGOs trying to promote messages of safe sex, HIV/AIDS, and gender rights.
Swazi Initiatives to Counter Stigma and Discrimination
With estimates of those infected with HIV at 170,000 or 33.4 percent of people 15 to 49 years old, Swaziland is among the most AIDS-affected countries in the world. In 1999, King Mswati III declared HIV/AIDS a national disaster. Later, the government established a Cabinet Committee on HIV/AIDS as well as an HIV/AIDS Crisis Management and Technical Committee, which was disbanded after it issued its national strategic plan at the end of 2001. The king formed a National Emergency Response Committee on HIV/AIDS (NERCHA) in 2002, which is administered by the prime minister’s office. NERCHA oversees implementation of the Swaziland National Strategic Plan for HIV/AIDS 2000-2005 and administers US$1.3 million in AIDS funds.
The strategic plan outlines a framework to guide a broad-based, national response that focuses on three areas: risk reduction (for infection); response management (for care, treatment, and support of those affected); and impact mitigation (to address the far-reaching effects of the epidemic on Swazi society). Under response management, the plan is to address stigma and discrimination to create a better environment for people with the virus. The strategies for accomplishing this include passing nondiscrimination legislation; developing policies to protect the rights of people with HIV/AIDS; educating communities to support those with the virus; ensuring that those who are affected receive counseling; and training community volunteers to provide care, support, and counseling.
There have been other initiatives. In early 2000, local leaders launched a national chapter of the Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa, which aims to work with the government, NGOs, the private sector, and local communities to limit the spread of HIV/AIDS and reduce the social and economic impact of the epidemic in towns and cities. In their declaration on HIV/AIDS, these local leaders address discrimination by committing to “raising awareness and changing attitudes on stigmatization, denial, rape, incest, multiple partners, and other unsafe practices.”
As part of a program to incorporate the HIV/AIDS work plans of all 11 municipalities, local leaders are being trained to address issues of discrimination and stigma and to be knowledgeable advocates on HIV/AIDS in their communities. The entire program is supported by a US$1.06 million grant from the African Capacity-Building Foundation, established and funded by the African Development Bank, United Nations Development Programme (UNDP), African governments, and bilateral donors.
Small initiatives are also coming from people with the virus. In 1993, people with HIV and AIDS formed the Swaziland AIDS Support Organization (SASO), whose goal is to share information and encourage support for people affected by the epidemic. With about 60 members and offices in three towns, SASO focuses its efforts on behavior change, support, information sharing, advocacy, and uprooting the stigma and discrimination faced by people living with HIV/AIDS and their families.
Government Focuses on Swazi Women and HIV/AIDS
The Swaziland government readily acknowledges that women have an increased vulnerability to infection. According to its policy document on HIV/AIDS, the reasons for this include:
- Limited knowledge and access to information about HIV/AIDS and sexually transmitted infections (STIs);
- Women’s economic and social dependence on men; and
- The asymptomatic nature of STIs in women, a factor known to hinder treatment and facilitate the spread of HIV.
The government recommends increased access to information and counseling and training in self-esteem, assertiveness, and decisionmaking to improve women’s negotiating position in sexual relationships and urges a review of religious and cultural traditions that can hurt women.
Gender studies by the UNDP have focused on some of the cultural practices that have added to women’s vulnerability to infection. For example, Swaziland is a polygamist society that allows men to have multiple wives and sexual partners. There are also arranged marriages and widow’s inheritance, whereby women whose husbands have died move in with their brothers-in-law who then become their surrogate husbands.
The research also found that the culture fosters submissiveness by women and male dominance. Swaziland’s women are considered legal minors: They cannot own property, enter into contracts, or receive bank loans without a male relative.
Setting the Agenda, Addressing Silence and Denial
The dynamics of stigmatization and discrimination in African societies are complex and not easy to overcome. Ignorance and misinformation intertwine with gender inequities, poverty, weak health care systems, and local customs. There is general agreement that African leaders in all areas — local, national, religious, and traditional — have a clear responsibility to encourage discussion, publicly acknowledge the ways in which they themselves are affected, and take other steps to address the silence and denial.
Although stigma and discrimination may never be eliminated, African government officials and researchers agree that interventions should aim to build responsibility and accountability. Experts attending the 2001 meeting held in Tanzania to set a research agenda on stigma and HIV/AIDS in Africa recommended action in four areas:
- The family: Responding with home-based care and other programs, bearing in mind that children face unique challenges and should be active partners rather than passive recipients in any intervention.
- Health care settings: Developing discharge and referral systems that are sensitive to people’s need for privacy; developing codes of ethics and professional conduct for health care services; and offering forms of redress when violations occur.
- The religious sector: Identifying language and doctrines that may be stigmatizing and promoting caring and nonjudgmental alternatives.
- The mass media: Developing media standards for journalists who report on HIV/AIDS; holding communicators accountable for reporting on the epidemic accurately, sensitively, and in a nonstigmatizing manner through the use of countrywide or region-specific monitoring mechanisms; and providing resources for sustained communication on HIV/AIDS that specifically addresses stigma.
The Blue Print for Action report published in July 2002 by a Global HIV Prevention Working Group, convened by the Gates and Kaiser Foundations, cites stigma as an obstacle to scaling up proven prevention strategies. In sub-Saharan Africa, openness and destigmatization will be crucial to efforts to curb the spread of this disease. At the same time, many agree that more research is needed to better understand the underlying causes of people’s negative responses.
Margo M. Kelly is a program development specialist and freelance writer based in Washington, D.C.
Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa (AMICAALL), Swaziland National Association of Local Authorities Declaration on HIV/AIDS: A Declaration by Mayors and Municipal Leaders of Cities and Towns of Swaziland on HIV/AIDS (January 2000).
AMICAALL, Swaziland Programme Start-Up Workshop Report (Piggs Peak, Swaziland: AMICAALL, Aug. 2001).
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Health & Development Networks and UNAIDS, Regional Consultative Report, Stigma and HIV/AIDS in Africa: Setting the Operational Research Agenda (Dar es Salaam, Tanzania, June 4-6, 2001).
Mark Heywood, “The AIDS Epidemic in Africa: Openness and Human Rights,” SAfAIDS News 7, no. 1 (March 1999).
HIV/AIDS Crisis Management and Technical Committee and Deputy Prime Minister’s Office, Swaziland National Strategic Plan for HIV/AIDS 2000-2005 (September 2000).
Horizons, Stigma and Discrimination Factsheet (Washington, DC: Horizons, January 2002).
Human Rights Forum, Human Rights Monitor, no. 16 (July 2001).
International Labour Organization, Code of Practice on HIV/AIDS and the World of Work (Geneva: ILO, 2001).
International Center for Research on Women (ICRW), “Addressing HIV-Related Stigma and Resulting Discrimination in Africa: A Three-Country Study in Ethiopia, Tanzania, and Zambia,” Information Bulletin (ICRW, March 2002).
John Murphy, “AIDS Smothers African Kingdom; Swaziland: AIDS is Destroying a Nation But Shame and Misunderstanding Muffle Outcries and Stifle a Response,” Baltimore Sun, Nov. 4, 2000.
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Swaziland Ministry of Health and Social Welfare, Policy Document on HIV/AIDS and STD Prevention and Control (August 1998).
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(December 2002) Mortality rates improved for both women and men in the second half of the 20th century. But these rates improved more rapidly for women than for men, so that until recently, the gender gap in life expectancy increased. In 1920, life expectancy at birth for females was two years greater than for males. By the 1970s, the female advantage was over seven years, but has declined since then, to six years in 2000 when life expectancy was 74 for males and 80 for females.
See Table (PDF: 4.6KB)
Historically in the United States, young women ran a high risk of dying during or after childbirth. Thanks to improved prenatal and obstetric care, death rates from pregnancy-related causes have fallen to very low levels.
Today, women have lower mortality rates at every age. Men are three times as likely as women to die from injuries (unintentional injuries, suicide, or homicide), and progress against those causes of death has been much slower than against other causes in the last 50 years. There is also evidence that men at all ages are less likely to seek medical care and less likely to comply with medical instructions than are women.
The widening of the gap during most of the 20th century can be attributed primarily to the fact that men smoked more than women. But in recent decades, the prevalence of smoking among women has increased while the prevalence among men has declined.
The sex difference in mortality rates, with females at an advantage, is found in nearly all human populations, and in many other species of mammals in which males are bigger than females.
A.M. Minino et al., “Deaths: Final Data for 2000,” National Vital Statistics Reports 50, no. 15 (2002); Ian P.F. Owens, “Sex Differences in Mortality Rates,” Science, 297 (September 20 2002): 2008-2009.