WHERE AND WHY ARE 10 MILLION CHILDREN DYING EVERY YEAR?
The first article in the series outlines the main epidemiological features of child death worldwide: over 10 million children dead each year, most from preventable causes and almost all in poor countries; six countries (India, Nigeria, China, Pakistan, Democratic Republic of Congo, Ethiopia) account for 50% of global deaths under age five, and 42 countries for 90% of deaths; around 40% of child deaths occur in sub-Saharan Africa and 35% in south Asia; 40% occur in babies younger than one month of age.
The authors highlight the main causes of death--diarrhoea, pneumonia, measles, malaria, HIV/AIDS and the underlying cause of undernutrition--for deaths among children under five, and asphyxia, preterm delivery, sepsis and tetanus for deaths among young or (newborn) babies. Pneumonia and diarrhoea predominate as the major diseases causing child death globally, with malaria and HIV/AIDS being major causes in some settings. Unsafe drinking water and a lack of breastfeeding are among the risk factors responsible for child deaths.
HOW MANY CHILD DEATHS CAN WE PREVENT THIS YEAR?
The second article highlights how a two-thirds reduction in childhood deaths could be achieved in the 42 countries with 90% of child deaths if known low cost measures--such as breastfeeding, use of insecticide-treated bednets, measles vaccination, rehydration therapy--are extended to provide maximum coverage in the areas where they are most needed. Current global coverage levels for most of these interventions are under 50%.
Lead author Gareth Jones comments: "There is no need to wait for new vaccines, new drugs, or new technology, although all these things must remain on the agenda as a basis for improving our efficiency and effectiveness in the future. The primary challenge today is to transfer what we already know into action; deliver the interventions we have in hand to the children, mothers and families who need them; and thus achieve the Millennium Development Goal of reducing under-five mortality by two-thirds by 2015."
REDUCING CHILD DEATHS: CAN PUBLIC HEALTH DELIVER?
This paper builds on the data from the first two papers and discusses the change in health-care infrastructure that will be required to deliver the interventions to substantially reduce child deaths. Authors of the paper comment that a 'one size fits all' approach is not the solution; instead they highlight how often a range of interventions relating to the relative strength of a country's health-care system is the best way to achieve maximum coverage for the required interventions. Community-based services could help deliver interventions in the absence of formalised health-care services. The authors comment how the strengthening of national health systems needs to be the long-term strategy. 'Achieving the millennium development goal for child survival is possible, but only if current strategies for delivering interventions are drastically improved and scaled up', they conclude.
EQUITY
Strategies to reduce the incidence of child deaths can only be effective if the inequalities in access to the necessary interventions are addressed. In a vicious cycle of poverty, the same children--the poorest--tend to miss out on all health interventions; these children are generally those with the greatest health-care needs. Lead author of the fourth article in the series, Cesar Victora, comments: "Socio-economic inequities in child survival exist at every step along the path from exposure and resistance to infectious disease, through careseeking to the probability that the child will receive prompt treatment with effective therapeutic agents. The odds are stacked against the poorest children at each of these steps. As a result, they are more likely than their better-off peers to die in childhood."
KNOWLEDGE INTO ACTION
The final article in the series is a clear call to action highlighting four major priorities:
1. Leadership. There is no global leadership today for child survival--no institution or individual is out in front, pioneering responses to recognized failures and needs, influencing technical and political agendas, directing investments and producing credible evidence that child mortality is decreasing as a result of specific actions.
2. Health systems. The longer-term goal must be systems of public health that are capable of defining needs, generating resources, managing programmes and people, delivering cost-effective services, and collecting and using data as the basis for improving the impact of their efforts.
3. Increased resources. The annual costs of required scaling-up of resources would be about US$1 billion for vaccinations, 4 billion for the treatment of childhood illness, and an additional 2.5 billion for malaria prevention and treatment for all age-groups combined. For comparison, it costs over US$4 billion to add two aircraft carriers to a fleet, and the annual expenditure on pet food in North America and Europe is around $17 billion.
4. Increased public awareness. A renewed effort is urgently needed to recreate the impetus of the 1980s, where a global movement reached beyond the public health community to mobilize parents, teachers, village chiefs, rock stars, sports figures and presidents. The actions needed were simple, clear and communicated consistently through all available channels. The interventions were available and generally affordable, even to the poorest.
An accompanying Lancet Commentary (published June 28) comments: 'We hope that the series will lead to debate on how to initiate and sustain momentum in child health without creating new bureaucratic structures or provoking political infighting. The series authors make no rash promises, but commit to organising meetings every 2 years to check progress on child survival and hold people accountable if none has been made. As the authors point out, this proposal alone is not enough "but is a long-term commitment to change and improve the state of child health".'
Series co-ordinator Jennifer Bryce comments: "There can be no further excuses for letting children die. We have effective interventions, we know that children and mothers living in poverty are systematically neglected, and we know that the resources needed are available but are not being used to tackle child survival. Reducing child deaths is an opportunity for success. It is the millennium development goal with the best chance of being fully achieved, on time by 2015. We need strong, coordinated leadership--from governments, from the United Nations, development agencies, and scientists. These leaders must be bold enough to focus on children and mothers rather than individual diseases, and brave enough to measure progress in terms of lives saved, rather than services delivered and money spent."
Richard Horton, Editor of The Lancet, comments: "Child survival is the most pressing moral, public health, and political issue of our time. The cruel neglect of the health of the world's children reflects gross failures at every level--within those global institutions charged with protecting child health, of a medicine more concerned about the fruitless technological quest for human perfection than simple low-cost preventive measures to end unnecessary death and disability, and of western societies that largely ignore children as a group with special needs and concerns. The way we think about the future of children's health is a reflection not only of our own moral compass but also of our vision for a peaceful and sustainable future world order. On the basis of the evidence presented in this Lancet series, the inescapable verdict is that we are failing the world's children--and our own futures."
ONGOING E-MAIL DEBATE AT THE LANCET
The Lancet will host a debate about the Child Survival series on its website, and welcomes contributions by e-mail:debate@thelancet.com.
Contacts for further media information:
Overall series co-ordinators:
Jennifer Bryce, Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland; T) +41-22-791- 2669; E) ryana@who.int.
Professor Cesar Victora, Universidade Federal de Pelotas, Pelotas, Brazil;
T) +55 53 271 2442; E) cvictora@terra.com.br.
Paper 1 (June 28): WHERE AND WHY ARE 10 MILLION CHILDREN DYING EVERY YEAR?
Professor Robert Black, Johns Hopkins Bloomberg School of Public health, Baltimore, USA; T) (Communications Office) Gina Coco ) +1 410 614 5439; E) gcoco@jhsph.edu.
UK contact: Dr. Saul Morris c/o Lindsay Wright, Press Office, London School of Hygiene and Tropical Medicine, UK; T) +44-0-20-7927-2073; E) Lindsay.wright@lshtm.ac.uk.
Paper 2 (July 5): HOW MANY CHILD DEATHS CAN WE PREVENT THIS YEAR?
Dr. Gareth Jones, c/o Alfred Ironside, Public Affairs; T) +1-212-326-7261; E) aironside@unicef.org.
UK contact: Dr. Saul Morris - see above
Paper 3 (July 12): REDUCING CHILD DEATHS: CAN PUBLIC HEALTH DELIVER?
Jennifer Bryce, WHO - see above
Paper 4 (July 19): EQUITY
Professor Cesar Victora - see above
Paper 5 (July 26): KNOWLEDGE INTO ACTION
Jennifer Bryce, WHO - contact details above
Professor Cesar Victora - contact details above
Dr. Duff Gillespie, David and Lucile Packard Foundation, Los Altos, USA; E) DGillespie@packard.org.
Journal
The Lancet