Kafil Yamin, Jakarta – Child malnutrition continues to be a blot on Indonesia's impressive record of poverty reduction in the last three decades.

Malnutrition is the underlying cause of 60 percent of all deaths of children under five years of age, according to the State of the World's Children 1998 report by the United Nations Children's Fund (UNICEF). The report ranks Indonesia 67th in the global list of under-five mortality with 336,000 deaths annually compared to the annual number of 4.73 million births.

This means Indonesia, which has cut poverty incidence from 70 percent to 14 percent in three decades, is worse off than South-east Asian neighbours like the Philippines, Malaysia or Vietnam.

UNICEF also says child malnutrition in the country was recorded at 35 percent. Though the figure has fallen from the 39 to 44 percent figure during the period 1994 to 1996, analysts say the decline is taking place slowly.

There are also other signs of poor child health, ranging from deficiency of iodine and Vitamin A and the prevalence of acute respiratory infections.

UNICEF officials in Jakarta point to the fact that iodine deficiency disorders (IDD) continue to cause high goiter rates especially in the eastern, poorer part, of Indonesia. In where IDD remains endemic, the rates of goiters are at 28 percent among school children and between 23 to 28 percent for pregnant women.

Goiter sufferers are often found in rural areas, like villages in Central and East Java and mostly in the islands of Bali, Nusatenggara and Lombok. But iodine deficiency problems are not always easily spotted, especially when no glob of flesh is readily seen on the neck.

"If the goiter sufferers are children, you won't see a glob of flesh on their necks," said Sunawang, nutrition programme coordinator at UNICEF Jakarta. "IDD is caused by more by natural factors," he said, linking micronutrient deficiency, poor diet and the environment.

"In eastern areas of Indonesia, iodine elements disappear from the soil surface due to natural processes, such as erosion, floods, etc. Food coming from such soil through farming and agriculture then have no iodine content," Sunawang pointed out. So "the only way is to add iodine to food."

In a 1987 presidential decree, the Indonesian government required all salt produced to be iodised. Producers who do not comply with this regulation are subject to punishment.

The salt iodisation campaign, commonly used in many developing countries, has worked smoothly in cities, where government orders are more easily carried out and monitored.

But that is not the case in remote villages, not least because of ignorance about the importance of iodine in diet. "There are cases where people consume uniodised salt because it is the only salt available in the marketplace," Sunawang said.

Inadequate child care and knowledge about health is also a factor in malnutrition and child deaths, the UNICEF report says.

Indonesian authorities have made impressive headway in spreading the word about oral rehydration therapy (ORT) to control diarrhoea in children, so that by 1994, overall use of ORT reached 99 percent.

But the other component of care of diarrhoea patients – giving sufficient fluids – was only practiced by 53 percent.

Thus, the UNICEF report says that diarrhoea remains the cause of 23 percent of under-five deaths in Indonesia. The same report says acute respiratory infections, often found among slum communities and poor villages, cause 40 percent of infant deaths.

Needless to say, child health is intertwined with maternal well-being. Maternal mortality remains high at 425 in 1992, though this has fallen from 450 per 100,000 live births in 1986.

Child health experts link this to poor access and coverage of antenatal care, noting poor existing capability to detect and refer 'at risk' obstetric emergencies. This means the country will be hard pressed to meet the goal of 225 deaths per 100,000 live births for this year.

Other figures shed more light on mothers' health. Almost two-thirds of Indonesian women are anaemic. The maternal anaemia rate stands at 40 percent, a situation unlikely to be addressed solely through the distribution of iron-folate tablets during pregnancy.

Sunawang said 26 percent of women still have inadequate dietary intake, which contributes a great deal to both child malnutrition and maternal mortality. While only 14 percent of the population have daily per capita energy intakes below the government-recommended daily allowance, experts say people need to better educated on dietary choices.

"Common people, including the rich, prefer to consume good-tasted foods than nutritious ones," said a medical expert who runs a health consultation programme on television.

UNICEF officials, however, add that Indonesia deserves credit for its success in eliminating vitamin A deficiency.

Two decades ago, more than two million Indonesians were affected by Vitamin A deficiency, which can cause blindness and damage the immune system. With UNICEF, the government distributed high-dose Vitamin A capsules to children ages one to five, reducing deficiency levels dramatically.

The rate of severe Vitamin A deficiency has declined by more than 75 percent, sparing the eyes, health, and lives of millions of children. Blindness among children due to vitamin A deficiency was eliminated in 1994.

Severe Vitamin A deficiency, however, persists in three provinces – West Java, Central Java and East Java – where half of all children under five had inadequate levels of vitamin A.

The government aims to eliminate vitamin A deficiency totally by the year 2000, among others by food fortification and intake of Vitamin A-rich food.

It is also giving high-potency Vitamin A capsules to mothers after they give birth. This, however, will require special effort since only 35 percent of births occur under medical supervision.