The chances of newborns surviving to adulthood have never been greater: in the past 20 years, rates of childhood death have fallen by more than half. Nearly all 193 United Nations member states have made tremendous progress. But within each country, disparities condemn many children to premature death.
A study in Nature this week zooms in on the 99 low- and medium-income countries where, in 2017, 93% of deaths of children under 5 happened (R. Burstein et al. Nature 574, 353–358; 2019). The authors estimate mortality for young children in each of 17,554 administrative regions from 2000 to 2017 — a remarkable level of detail.
The overall result is encouraging: 60% of the districts show sustained progress. But a closer look reveals continued inequalities. The research team calculates that 58% of the 123 million deaths mapped over 17 years were preventable. If all areas had mortality rates equal to the best-performing regions in their country, these deaths would not have occurred.
Richer areas, including capital cities, typically have much lower rates of child mortality. Poor governance can lead to the disproportionate allocation of public resources to elite groups. Deaths of small children spike in areas of poverty — where minority ethnic or religious groups, Indigenous peoples and other people who experience discrimination are likely to live. Discrimination against women leads to failure to prioritize maternal health; discrimination against ethnic or religious groups results in inadequate services for adults and children. And child deaths often accompany other human-rights violations. Insecurity, violence and conflict affect millions of children.
The overarching lesson of these detailed mortality maps is that we must frame health programmes very broadly. Tackling child mortality requires efforts across all government functions — providing access to medical treatment is just one element. If governments are to uphold citizens’ rights to health, they must consider the social determinants of children’s well-being.
As a paediatrician treating the families of political prisoners in the 1980s during the dictatorship of Augusto Pinochet in Chile, I saw children who were not only ill, but also impoverished and traumatized. Back then, I could try to cure their sickness, but I could not provide a nourishing environment for them to grow up in. That is something I strove to do through policy in my work as Chile’s minister for health and defence (2002–06) and president of Chile (2006–10 and 2014–18), and subsequently as a global health advocate, leader of UN Women and now UN high commissioner for human rights. Throughout my career, I have seen that improvements are feasible, cost effective and durably beneficial.
In Chile, death rates for children under 5 dropped from 148 to 7 per 1,000 between 1961 and 2018 — an unprecedented improvement. Since 1990, Chile’s maternal mortality decreased from 31 to 13 per 100,000 live births, and infant mortality from 16 to 6 per 1,000. Disparities between districts also decreased, with the largest mortality reductions in the poorest areas.
How did we succeed? Our programmes focused on goals far beyond that of making sure that sick children could see a doctor.
As president of Chile, I knew that reducing child mortality required ensuring access to care, monitoring pregnant women’s health and promoting vaccination campaigns. It also meant providing food security, in part through schools that offer nutritious meals. The ‘Chile Grows With You’ programme, launched in 2006, was the first of its kind in Latin America. It assists with offering education, maternity care and health services to families.
Providing adequate services is about more than resources. If women feel demeaned or inadequately consulted about their own bodies at hospital or physician visits, or if they are made to wait for hours at appointments, they might not turn up for prenatal care. We paid attention to differing needs across the country. We installed signage in Indigenous languages in key areas, introduced intercultural facilitators and encouraged inclusive approaches.
Truly universal and high-quality health coverage demands policies that extend beyond the strictly medical framework. It requires measures to uphold the whole range of human rights and to combat inequality and deprivation. Policies for decent housing, better labour rights, expanded childcare and unemployment benefits, access to basic services such as clean water — these are the types of reform that must be recognized as essential to health.
Childhood-mortality data reveal the stark realities of inequality. And improvements in these data mean fewer tragedies for families. They also shift the future of whole communities, potentially for generations. The World Bank has estimated that up to 30% of the differences in countries’ per capita gross domestic product can be attributed to ‘human capital’ — essentially, education, training and health.
Three decades ago, the Convention on the Rights of the Child, which has become the most widely ratified human-rights treaty in history, emphasized the right of every newborn to the highest attainable standard of health. However complicated the ultimate causes, the factors that contribute to childhood deaths come down to failures to treat broader ills: poverty, disempowerment, discrimination and injustice.
Hard data, like those published this week, must be followed up by action across the whole spectrum of government and society.
Nature 574, 297 (2019)