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Worldwide Decline in Early Childhood Death
By David F. Duncan, DrPH, FAAHB

Deaths among children under five are declining at an increasing rate.

Worldwide 7•7 million children younger than 5 years old are projected to die in 2010, a substantial decline from 11•9 million deaths in 1990 and 16 million in 1970 according to a new report published in the British medical journal The Lancet. The report, titled "Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970—2010: A systematic analysis of progress towards Millennium Development Goal 4", is based on 40 years of data from 187 countries across 21 regions of the world. Previous reports have shown similar trends but this new study, based on more detailed information and applies improved statistical methods, presents the most positive findings yet. These results show that global efforts to save children’s lives are not only working, but are succeeding faster than expected.

The projection of 7•7 million deaths in 2010 consists of 3•1 million neonatal deaths, 2•3 million postneonatal deaths, and 2•3 million childhood deaths (deaths in children aged 1—4 years). The largest number of child deaths occur in sub-Saharan Africa (49.6% of the total) and south Asia (33•0%), with less than 1% of deaths in children younger than 5 years occurring in high-income countries.

The global decline from 1990 to 2010 is 2•1% per year for neonatal mortality, 2•3% for postneonatal mortality, and 2•2% for childhood mortality. In 13 regions of the world, including all regions in sub-Saharan Africa, there is evidence of accelerating declines from 2000 to 2010 compared with 1990 to 2000. Within sub-Saharan Africa, rates of decline have increased by more than 1% in Angola, Botswana, Cameroon, Congo Republic, Democratic Republic of the Congo, Gambia, Kenya, Lesotho, Liberia, Rwanda, Senegal, Sierra Leone, and Swaziland. Some parts of Latin America, North Africa and the Middle East have had declines as steep as 6 percent a year. The lowest death rates, measured per 1,000 live births, are in Singapore (2.5) and Iceland (2.6), while the highest are in Equatorial Guinea (180.1) and Chad (168.7). The United States, with a rate of 6.7 deaths per 1,000 live births, has one of the worst levels of child mortality among the wealthier nations.

Progress has been accelerated, even in many of the poorest environments, through integrated, evidence-driven, community-based health programs focused on addressing the major causes of child death -- pneumonia, diarrhea, newborn disorders, malaria, HIV, and hunger. The continuing decline in early childhood deaths can clearly be attributed to increased use of key public health interventions, such as immunizations (including measles vaccinations and now including pneumonia and rotaviral vaccines), distribution of insecticide-impregnated bed nets to prevent malaria, and Vitamin A supplementation.

Education about HIV, condom distribution, syringe exchange programs, and increasing availability and reduced cost of anti-retroviral drugs have all played a major role in reducing mother-to-infant transmission of HIV and subsequent child deaths. In the words of Mickey Chopra, Chief of Health for the United Nations Children’s Fund (UNICEF), “we are turning the tide in terms of HIV in young people.” Thanks to successful health education, "the message is getting through. Behaviour change is happening, condom use is going up and so we feel that this is a success story.”

Where these interventions have increased, positive results have followed. Dr. Chopra makes the point that countries whose governments have “fully supported child survival and primary care” have improved quickly. He cited Malawi, Ethiopia, Tanzania and Rwanda as examples of success. He warns, however, that the improvements in these and other poor nations could easily be reversed, because the underlying poverty has not changed. “If we don’t continue to do these interventions and fund these interventions, we’ll start to see an increase again,” he warned.

Christopher J. L. Murray, one of the authors of the report and Director of the Institute for Health Metrics and Evaluation at the University of Washington, stated in a New York Times interview that he finds the improvements in Africa especially encouraging. “The very slow progress in Africa has led some people in global health to argue there should be more emphasis on tackling child mortality outside of Africa, especially India. We think it’s important to call out this accelerated progress. The last thing we’d like to see, when at last something is happening, is to pull the plug and move elsewhere.” While I certainly support the idea of doing more in Asia, I agree fully with Dr. Murray that we should not do so at the cost of doing less for the children of Africa.

This new report has implications for the Millenium Developmental Goal set by the United Nations that calls for reducing death rates in children under 5 by two-thirds from 1990 to 2015. Mortality rates are moving in the right direction and they are doing so faster than we thought they were. Nevertheless, not many countries seem to be on track to reach the goal by 2015.

Among those not on track is the United States. Still saddled with an inefficient fee-for-service payment system and an insurance system that turns a greater profit by rejecting claims for treatment, the U.S. continues to perform poorly on this and most measures of health outcomes. Our policymakers, as well as those in poorer nations, need to make a real commitment to meaningful reform in how we provide for the health of the public. This report shows how much can be achieved when evidence-based public health practices are adopted. The child we save may be your own.

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David  F. Duncan
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