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A two-month-old black rhino toddles unsteadily into the clearing to adoring oohs and aahs, her back protected from the bright sun by a red cloth, white salve on her ears to help heal some rough spots, and a gentle and patient guide beside her. This Kenyan baby will be nurtured for two more years at this suburban preserve before release into the wilds of Tsavo National Park. At that point, a normal lifespan’s survival would be nearly assured, despite having been abandoned by her mother for reasons we’ll never know, possibly after a premature birth.

The attention lavished on this rarest of animals does not seem untoward, but is a stark contrast to what caring parents just a few kilometers away can offer their own infants. Kibera, the most populous slum in Africa, with a million people squeezed into an area smaller than New York’s Central Park, presses up against bustling Nairobi, Kenya’s capital and largest city. In shacks reaching to the horizon, babies are born and lives lived out, for those who survive the first year and then the first few, the most vulnerable periods. Human infant hazards are different from those facing an unprotected black rhino, but just as lethal. As in other low-income countries, lack of an inexpensive antibiotic can mean the difference between life and death from all-too-common pneumonia. In the US and other rich countries, the antibiotic would be available even to a poor child. But in the United States, most cases of pneumonia have been banished from infancy and childhood by routine vaccination against Haemophilus influenzae (the “Hib” vaccine) and the common Pneumococci. In Kenya, Hib vaccine was introduced in 2002 and pneumococcal vaccine for infants is planned. How big an impact the Hib vaccine is having is still unknown, however, and the future impact of pneumococcal vaccine also may not be known for years because surveillance at an appropriate scale is also lacking. What is known is that the mortality rate for infants is still among the world’s highest—about 70 per 1000 live births (compared with <10 per 1000 in the US and UK)—and perhaps a fifth of those deaths are from preventable and treatable pneumonia.

What about another ever-present killer of infants: the common diarrheas that all parents contend with? These are even more common where water and food may be contaminated with the gut pathogens that can be so dangerous. But one of the great medical breakthroughs of the 20th century—oral rehdration therapy, or ORT—has solved that problem. Hasn’t it? It turns out that Kenya is one of the few countries where the use of ORT is declining and plenty of infants are dying from the dehydration that accompanies “watery” diarrhea (in contrast to bloody diarrhea or dysentery, which does call for antimicrobials), not least of all in Kibera. The Centers for Disease Control and Prevention (CDC), which has a substantial and permanent presence in Nairobi , has colllaborated on a study in Kibera (where it regularly conducts studies and provides health care) to find out why this is so. The study is complete but not yet published, and I won’t give away the results. This lesson is clear, though: successes must be protected and not taken for granted, particularly if they depend upon individual actions and the knowledge that underpins them. Mothers in the 1970s and 1980s might have been well informed about the benefits of ORT, but the children who survived because of it, now parents themselves, are not, and may have abandoned its use.

As we consider what policies might help maintain the effectiveness of antibiotics through GARP, these early glimpses foreshadow the challenges ahead.