Elsevier

The Lancet

Volume 361, Issue 9376, 28 June 2003, Pages 2226-2234
The Lancet

Series
Where and why are 10 million children dying every year?

https://doi.org/10.1016/S0140-6736(03)13779-8Get rights and content

Summary

More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another, highlighting the need to expand understanding of child health epidemiology at a country level rather than in geopolitical regions. Other key issues include the importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multiple concurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most often associated with child deaths. A better understanding of child health epidemiology could contribute to more effective approaches to saving children's lives.

Section snippets

Where do most child deaths occur?

The estimate for global child deaths in 2000 is 10·8 million.7 In this series, data from 2000 will be used throughout because they are most complete for this period and little has changed in the past 2 years. About 41% of child deaths occur in sub-Saharan Africa and another 34% in south Asia.7 Because there is substantial variation in death rates within these regions, planning for health interventions should take place at a national level. The incomplete and unreliable nature of these data in

Risk factors for child mortality

Unhygienic and unsafe environments place children at risk of death.2, 12 Ingestion of unsafe water, inadequate availability of water for hygiene, and lack of access to sanitation contribute to about 1-5 million child deaths and around 88% of deaths from diarrhoea.2, 12 Other health-related behaviours, such as birth spacing, are also important risk factors for child mortality.13

Infants aged 0–5 months who are not breastfed have seven-fold and five-fold increased risks of death from diarrhoea and

Underlying causes of death

WHO's work on the global burden of disease, consistent with the International Classification of Diseases (ICD), stipulates one cause of death, which is considered to be the “disease or injury which initiated the train of morbid events leading directly to death”.18 This measure ensures that the sum of deaths from all possible causes will not exceed the total number of child deaths. However, such a classification oversimplifies the situation in low-income and middle-income countries where serious

Classification

All countries need sound epidemiological information to prioritise, plan, and implement public health interventions. Vital event registration that includes cause-of-death data is used to establish the cause structure of mortality in high-income and some middle-income countries, but these are generally not available for the countries where 90% of child deaths take place. Of these countries, only Mexico records more than 95% of causes of death.27 Where coverage is incomplete, the poorer segments

Synergy in causes of death

An interaction of two health disorders can have a synergistic effect on mortality—ie, a rate of death that is greater than the sum of the two individual rates of mortality. This has been documented most clearly for the relation between being underweight and infectious diseases.24, 35 For example, children who are mildly underweight (−2≤z scores<−1) have about a two-fold higher risk of death than those who are better nourished. This risk increases to 5–8 fold in moderately (−3≤z scores≤−2) to

Conclusions

Child health epidemiology is developing and increasingly can provide information useful for public health planning, monitoring, and evaluation. Ideally, information on causes and determinants of death would be available for planning at national or subnational levels. Our epidemiological profiles show the extent of variation between major causes of death even within commonly used regional groupings, which highlights the need for disaggregation at regional and global levels to allow public health

Search strategy

The search strategy for the model used to estimate proportionate causes of death has been described.32 Estimates of the importance of risk factors were taken from published results.12 For our comorbidity analyses we also contacted researchers and directors of demographic surveillance areas in low-income and middle-income countries.

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