About 90 percent of child deaths worldwide occur in just 42 countries – and about one-fourth of these deaths occur before age 5 in the poorest countries, such as Angola and Niger.

Yet, 8 million of the 11 million childhood deaths worldwide each year could easily be prevented, says a Cornell University expert, writing in the authoritative medical journal The Lancet . That's because almost 60 percent of deaths of children under 5 in the developing world are due to malnutrition and its interactive effects on preventable diseases.

"Every single day – 365 days a year – an attack against children occurs that is 10 times greater than the death toll from the World Trade Center," says Jean-Pierre Habicht, professor of epidemiology and nutritional sciences at Cornell. "We know how to prevent these deaths – we have the biological knowledge and tools to stop this public health travesty, but we're not yet doing it."

Habicht is a member of the Bellagio Child Survival Study Group, made up of leading child-health researchers, that has authored a series of five articles in The Lancet on how to prevent the global toll on young children. The first article is published in the June 28 issue; the other four will follow in the next four consecutive issues.

Only 10 years ago, child-health experts believed that malnutrition played only a negligible role in child mortality in the developing world. Then, Habicht and his colleagues at Cornell published a study showing that the majority of these childhood deaths were due to the interactive effect of malnutrition on disease. They also reported that more than 80 percent of malnutrition-related deaths were due to mild-to-moderate malnutrition rather than severe malnutrition.

The Cornell nutritionists had already shown that malnutrition worsens with illness in malnourished children. This compares with the effects of the same illnesses on well-nourished children, who do not become malnourished. Researchers report that malnourished children are up to 12 times more likely to die from easily preventable and treatable diseases than are well-nourished children."Malnutrition kills in two strokes -- it makes children more vulnerable to severe malnutrition if they fall ill, and this, in turn, contributes substantially to the global level of malnutrition that kills if a child is ill," says Habicht. "Thus the first step in preventing child death is to make sure that every child is well nourished, which is both scientifically and economically feasible."

Habicht points out that both malnourished and better nourished children are killed by a few preventable diseases, such as measles, malaria, diarrhea and pneumonia, which can be prevented or managed effectively to prevent death. "These are also the diseases that kill malnourished children, so that dealing with these diseases is a first step for well-fed children and a fall-back step for malnourished children. Preventing deaths from these diseases costs only pennies per year," Habicht says.

Sadly, the childhood death toll remains high despite effective and inexpensive preventions because of problems at upper levels of organizations, Habicht and the Bellagio Group assert. Either families don't get the information they need to seek medical care or help is not available because the organization of services is inadequate. "These issues turn out to be more difficult to resolve than the biological challenge was," Habicht says. "Remarkably little research is devoted to developing, testing and implementing strategies for care compared to the amount of research that goes into improving the biological effectiveness of care."

The series of papers in The Lancet calls for a strategy to make health care more equitable, preventing one-third to one-half of childhood deaths without an increase in resources.

"It is, however, naive to think that the research, development and implementation of new strategies can be undertaken without more resources devoted to health care, even if in the long run they will become less expensive as efficiency improves," Habicht says. Unfortunately, international funding for health care in developing countries is flagging. Washington is proposing to spend one-third less on international maternal and child health in the next federal budget, he says.

"We know how to prevent the deaths of millions of children," Habicht concludes. "Now we just have to do it."