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At this time of awful news of the needless death of children, there comes reason for optimism about the health of the world’s youngest.
Income and growth data don’t capture the tremendous gains in quality of life in poor countries.
Sierra Leone, Malawi, Laos, Bangladesh and Nicaragua are among the poorest nations in the world. The state of countries like these is often cited to illustrate the failures of development, the persistence of poverty. But here’s what has changed: Bangladesh dropped its death rate of children under 5 by two-thirds between 1990 and 2010. Child mortality is down by 56.5 percent in Malawi since 1990, 63.8 percent in Sierra Leone, 55.6 percent in Laos, and 61.9 percent in Nicaragua.
As remarkable as these gains may be, more remarkable still is the fact that they are far from alone. A massive study published last week called the Global Burden of Disease report found that in the past 20 years, the death rate of children under 5 has dropped in every country in the world save three — Kuwait, Tonga and Zimbabwe. Stunning gains took place in all regions, under all economic and political systems and at all income levels: El Salvador, China, Oman and Portugal all saw drops of more than 70 percent. Even North Korea did just about as well as South Korea — a 49.9 percent drop in the North, 55.1 percent in the South.
What’s more, the gains are accelerating: from 1990 to 2000, according to Unicef (which uses different measures in its own reports, and so comes up with somewhat different numbers), global decline was 1.8 percent per year. Since 2000, the rate has dropped 3.2 percent per year.
The Global Burden of Disease report, coordinated by the University of Washington’s Institute for Health Metrics and Evaluation, assembles data on all diseases, in all countries, for all ages. It is so big that its first set of papers and comments takes up the entire issue of The Lancet medical journal (the first time any study has occupied the whole journal) and has 486 unique authors from dozens of countries. The study sorts out what kills, sickens and disables us. Last week the study released overall numbers. It will be supplemented next year by numbers that examine the impact of each disease in each country.
The headlines: compared with 1990, the last time the study was done, child deaths have dropped precipitously, but deaths of young and middle aged adults are rising. People are living much longer, but those lives are not as healthy. Chronic diseases, like diabetes, hypertension and cancer — formerly known as diseases of the wealthy — have overtaken the classic infectious diseases of the poor, like diarrhea, pneumonia and malaria as the leading cause of death everywhere except in sub-Saharan Africa. Obesity is the new hunger.
Some of the bad news is a side effect of the good news. Chronic diseases now take a larger percentage of lives (that’s bad) because deaths from infectious diseases have declined (that’s good). As life expectancy increases (that’s good), the chronic disease of old age become more common (that’s bad.)
But there are worrisome factors as well. The death rate in young adults is high in part because of AIDS and rising rates of violence. And as obesity spreads, chronic illnesses like diabetes and stroke are killing younger and younger people.
In the Fixes column, we focus on what works and why. What produced the incredible drop in child mortality?
The gains did not come by conquering the celebrity diseases of malaria and AIDS — those produced the two most important jumps in child deaths, although the death rate from malaria did drop by 85 percent in South Asia. (That does not mean that the vast and successful global effort to fight these diseases is failing; a million more children would be dead if not for the malaria push over the last decade. But it is not enough.) Instead the big drops came in deaths from measles, diarrhea, pneumonia, malnutrition, tuberculosis and neonatal tetanus.
This achievement is not a product of increasing wealth; researchers believe that’s only a small part of the reason children are doing so much better everywhere. Economic growth is clearly a huge factor in China, but some of the biggest gains in child survival have come in countries that are stagnating economically. “You can still make quite substantial improvements in child survival without decreasing poverty levels,” said Mickey Chopra, Unicef’s director of health. “Countries such as Nepal, Rwanda, Niger — all of whom have not had much economic growth per capita — have more than halved their child mortality rates. That means there’s no excuse for not making faster reductions in child mortality.”
Half of all gains in child survival are the product of increases in women’s education.
More important are a series of fairly cheap global programs – vaccines, nutritional supplements, family planning, oral rehydration salts to treat diarrhea, bed nets, improved hygiene and sanitation, cleaner water, antiretroviral drugs to prevent mother-to-child transmission of H.I.V. We take a lot of this work for granted now, but every one of these efforts is fairly new. Unicef and the World Health Organization began their global effort to vaccinate children against common diseases only in 1985.
Some of these programs, like vaccines, have been relatively straightforward to deliver. (Not as straightforward as they should be, however — this week, the Taliban assassinated five women delivering polio vaccine in Pakistan.) But programs that require long-term behavior change have been more difficult. Still, there has been considerable success promoting breastfeeding, showing mothers when and how to use oral rehydration therapy, and boil water, and teaching people about handwashing and digging and using pit latrines.
The foundation for many of these programs is the democratization of health care. Historically, governments have spent their health budgets on urban hospitals — serving people with money and political clout. In the last few decades, however, governments have also expanded health care to the rural poor — often through the training of community health workers.
This saves lives with acute care — in sub-Saharan Africa, according to Unicef, the percentage of child pneumonia cases where families sought appropriate medical care rose since 2000 to 46 percent from 36 percent. But the real impact has come in the change community health workers have wrought in everyday habits. Children are now more likely to survive pneumonia not only because they are more likely to get antibiotics, but also because they are in general healthier — breastfed for longer, better fed, drinking cleaner water.
Community health workers have also been key to the drop in neonatal deaths. In villages with community health workers, fewer women give birth unattended or attended by midwives who lack modern medical knowledge.
Perhaps the single most important reason for the drop in child deaths is not a health campaign at all. Researchers analyzing education and child mortality patterns concluded that just over half of all gains in child survival are the product of increases in women’s education. (Economic growth, by contrast, accounts for just 7.2 percent of the gains since 1970.) With every extra year of education for women of child-bearing age, child mortality drops by 9.5 percent.
Educated women are more likely to know about and adopt better health practices. They postpone childbearing and have fewer children. They are more likely to take a sick child to see a doctor or health worker. Educated mothers are more likely to survive and be there for their children.
The improvements in child survival have been dramatic, yet they do not seem to have altered many people’s fatalism about development or willingness to write off much of the world as doomed to eternal misery.
A new book, “Getting Better,” by the economist Charles Kenny, explains the disparity: when we measure how countries are doing, we measure income or economic growth. In most of the world, those figures have been dismal — especially in sub-Saharan Africa.
But Kenny argues that income and growth measures don’t capture the tremendous gains in quality of life. Someone who lives on two dollars a day today has far better health, education, gender equality, security and human rights than someone who earned two dollars a day in the past. For example, a poor African child had virtually a zero chance of being vaccinated in 1974. Today an equally poor child in an equally poor country would have a 77 percent chance.
Kenny credits the global spread of new technologies and ideas — but also rising expectations. For hundreds of millions of people, marrying off their 13-year-old was just what was done. Now sending her to school instead is the new normal. People are demanding more services from their governments — and governments are demanding more of one another. Why have advances in child survival sped up since 2000? One plausible reason is that that was the year the United Nations set the Millennium Development Goals — ambitious targets to be met by 2015. The M.D.G.’s were not just United Nations blather — what gets measured gets done. “The M.D.G.’s have been a key factor,” said Chopra. “They have been very important in drawing political attention, which in turn has been one of the critical success factors.”
Millennium Goal 4 is a reduction of under-5 child deaths by two-thirds compared with 1990 figures. It will probably not be met; 7 million children will still die this year from preventable causes. Yet there is no doubt we know how, and it is hard to think of a more sweeping accomplishment than the results so far.
Happy holidays, everyone.
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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author of, most recently, “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”
