Global Health Policy: Bending the Curve in Child Survival

By Orin Levine in Child Mortality

In the United States and Europe, child deaths are incredibly rare.  They occur at a rate of less than 1 in every 100 children born and are almost never due to preventable causes like tetanus or pneumonia.  Indeed, when even a few preventable deaths occur – as happened this last year in California with an outbreak of whooping cough deaths – it creates outrage and media coverage.

In the rest of the world, as many as 15 in every 100 children born will never reach their 5th birthday.  That’s over 7 million child deaths in a year – deaths that occur overwhelmingly in poor communities and from preventable causes.

Reductions in child deaths are occurring and have recently been heralded as the best story in international development. But the current rate of decline, while impressive, remains too slow, and will take the better part of this century to reach equity in terms of child survival between rich and poor countries.

This week in Washington, D.C., a group of world leaders and international organizations will call to end this ongoing inequality in child death rates.  In an effort to make sure that every child, everywhere gets a fifth birthday, the Governments of the United States, India, Ethiopia and UNICEF are convening a Child Survival Call to Action that aims to drive down the risk of child death to roughly equivalent levels in all countries of the world by 2035.

Understanding where children die and what diseases kill them is a critical first step to preventing these deaths.  Each year UN agencies like the World Health Organization, with support from Johns Hopkins Bloomberg School of Public Health and others, estimates how many children died in the preceding year and what diseases caused those deaths.  This helps focus prevention efforts in the right places and against key diseases.  This is important because sometimes countries with high rates of child deaths – like India or Angola – aren’t the ones you’d expect, and ones that you’d expect to be higher – like Bangladesh – actually aren’t.

At least as important, it often points out that unglamorous diseases like pneumonia, diarrhea, and hypothermia in newborns are even more important causes of child deaths than better known diseases like tuberculosis or AIDS.  This helps target interventions against the most important causes of child death instead of the best known causes.

Here is what is currently known about the who, what, where and when of childhood deaths, and a few key steps on how to address them in the next twenty years:

Where children die:

Child deaths are concentrated in a relatively small number of countries, with just 5 countries – India, Nigeria, Democratic Republic of the Congo, Pakistan, and Ethiopia – accounting for almost half of child deaths worldwide.  And 80% of child deaths occur in just 24 total countries.  In short, a focused effort in a relatively small number of countries can help make large gains.

When children die:

Newborn babies have the highest risk of death.  Typically, 30-40% of all deaths in children less than five years old occur during that first month of life.  Also, importantly, preventing neonatal death is typically the most challenging area of improving child survival.  In the past decade, the rate of newborn deaths has declined at a pace that is about 50% lower than that observed in older children.

Which children die:

Children who live in rural areas, who are born into the poorest communities, and those born to mothers with little or no formal education are the most likely to die, as illustrated below by data from Nigeria.

Under-5 Mortality Rate in Nigeria (per 1000 children), 2008. 

Source: Nigeria Demographic and Health Survey, 2008

After children survive the first month of life, the most important killer diseases of children are pneumonia, diarrhea, and, in Africa, malaria.  The risk of death from these diseases is increased when children are malnourished, suffer from a lack of important vitamins and nutrients, or have underlying diseases like AIDS or sickle cell disease.

With this knowledge, it’s possible to bend the curve and create a sharper, steeper decline in child deaths by increasing the deployment of existing interventions to the right places at the right time.  Ultimately, to meet the ambitious target levels called for in the Child Survival Call for Action,, innovations around new technologies and scaling up non-health interventions like female education will also be required.  But the journey of the next twenty years starts with at least the following key steps:

• a focused effort to improve newborn health and survival, probably best accomplished by linking these efforts with maternal health initiatives;
• increased efforts to combat pneumonia and diarrhea everywhere, and malaria in Africa;
• a concentration of investments in a limited number of countries where the bulk of these child deaths occur;
• locally adapted efforts to deliver services to poor communities especially those in rural areas
• and a large increase in systems that monitor births and deaths in developing countries.