Child mortality

From 1960 to 2002, the rate of under-5 mortality around the world steadily declined, largely because of expanded childhood immunization coverage, improved water and sanitation, and wider provision of medical treatment, such as antibiotics for respiratory infections. From 1990 to 2001, however, the under-5 mortality rate increased or remained stagnant in 23 countries. In another 53 countries (including China), the decline in under-5 mortality was less than half the 4.3% per year required to reach the fourth Millennium Development Goal of reducing under-5 mortality by two-thirds in the period 1990–2005. Progress has been slow in sub-Saharan Africa because of HIV/AIDS and, until very recently, the increasing prevalence of malaria, which is now widely resistant to the first-line drugs chloroquine and sulphadoxine–pyrimethamine.

Every year, an estimated 4 million babies die in their first month, accounting for 38% of all deaths among children under 5. Causes of death include infections (neonatal sepsis, pneumonia, diarrhoea, and tetanus, 36%), complications due to preterm birth (27%) and asphyxia (23%) (Table 3.1.2). Saving most of these babies does not require intensive care. Sri Lanka, to take one low-income country as an example, has lowered its neonatal mortality rate to15 per 1000, less than one-third of the rates typical in sub-Saharan Africa, without intensive care. Similar approaches would address the neglected global burden of over 3.2 million stillbirths each year.

Between 1990 and 2002, there were declining trends in deaths from acute respiratory infections (from 2.5 million to 1.9 million), diarrhoeal disease (from 2.4 million to 1.6 million), measles (from 0.8 million to 0.5 million), and injuries (from 0.6 million to 0.3 million). These improvements were partially offset by increases in under-5 mortality from malaria and HIV/AIDS (Fig. 3.1.1). From 1990 to 2001, child deaths due to malaria doubled from 5% to 10% worldwide and increased from 15% to 22% in sub-Saharan Africa, where few effective antimalarials are available.

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Fig. 3.1.1

Under-5 deaths from AIDS, malaria, and other causes per 1000 births in sub-Saharan Africa, 1990 and 2001.

Reproduced from Disease Control Priorities in Developing Countries (2nd Edition), with kind permission from The International Bank for Reconstruction and Development, The World Bank.

Adult mortality

Ageing populations and changing lifestyles across the globe contribute to noncommunicable diseases that are imposing tremendous burdens. In 2001, cardiovascular disease, cancer, chronic respiratory illness, diabetes, and psychiatric conditions accounted for two-thirds of deaths in over-5 (see Table 3.1.3). Cardiovascular disease (including stroke) in low- and middle-income countries killed more than twice as many people in 2001 as did AIDS, malaria, and tuberculosis combined. In 2001, about 11.1 million people over the age of 5 in low and middle-income countries died of cardiovascular disease (including stroke), 4.9 million died of cancer, 2.4 million died of chronic respiratory disease, and 0.7 million died of diabetes—altogether, 25.2 million of the total 38 million deaths in over-5s in developing countries that year (Table 3.1.3). Deaths from ischaemic heart disease and stroke are expected to triple in sub-Saharan Africa, Latin America, the Middle East, and North Africa.

The largest increase in noncommunicable diseases is predicted to occur in low- and middle-income countries, which continue to suffer the burden of communicable diseases like malaria, tuberculosis, and HIV/AIDS. This ‘double burden’ is reversing many of the gains from expanded immunization and clean water and sanitation. Noncommunicable conditions, generally chronic, are overwhelming fragile health systems that are struggling with short-duration morbidities imposed by communicable diseases.

In high-income countries, the likelihood of dying from a chronic disease has declined dramatically. Among men over 30 in the developed world, for example, death rates from heart disease dropped by more than 50% between 1970 and 2005, from 600 to 800 per 100 000 to 200 to 300 per 100 000. The death rate for Brazilian men was 300 per 100 000 in 1980 (compared with 500–600 in high-income countries) but has remained unchanged since. The World Bank predicts that chronic conditions will be the leading cause of death in low-income countries by 2015.

Cardiovascular diseases are responsible for 17 million deaths worldwide each year. Of these, 13 million deaths are in low- and middle-income countries and represent more than a quarter of all deaths in these countries. Most cardiovascular deaths result from ischaemic heart disease (5.7 million) or cerebrovascular disease (4.6 million). Because such deaths occur at older ages, they are a smaller fraction of the total disease burden in DALYs—12.9%.

Tobacco use accounts for a substantial and avoidable fraction of cardiovascular disease and cancers. In 2000, the number of tobacco-related deaths in developing countries about equalled the number in high-income countries; by 2030, developing countries may have more than twice as many. Controlling smoking is a crucial element of any nation’s strategy for preventing cardiovascular disease and promoting health more generally. Preventing the initiation of smoking is important because addiction to nicotine makes stopping smoking very difficult, even for those who want to quit. However, far more lives could be saved between now and 2050 by helping current smokers to quit. Reducing smoking levels is well within the control of public policy. Taxation is the principal proven instrument, but complementary measures such as bans on smoking in public places and tobacco advertising are also important.

The main risk factors for cardiovascular disease, such as high blood pressure, high cholesterol, smoking, obesity, excessive alcohol use, physical inactivity and poor diet account for very large fractions of the deaths (and even more of the burden) from ischaemic heart disease (collectively accounting for 78% of deaths in low- and middle-income countries) and stroke (61%). Measures to reduce the levels of those risk factors are the goals for prevention. Unlike the favourable experience with controlling tobacco use, attempts to change behaviour leading to obesity, hypertension, and high cholesterol appear to have had little success at a population level. However, many promising approaches remain to be tried. Common sense suggests that they should be initiated even while efforts to develop and evaluate behaviour-change packages are ramped up.

If sustained behaviour change proves difficult to achieve, medications have the potential to reduce cardiovascular disease risks by 50% or more. Pharmaceutical interventions to manage two major factors, hypertension and high cholesterol, are well established and are highly cost-effective for people at high risk of a stroke or heart attack. The low cost and high effectiveness of drugs to prevent the recurrence of a cardiovascular event have made their long-term use potentially cost-effective in low-income environments.

Lifelong medication for cardiovascular disease, however, like medication for psychiatric disorders, requires not only low-cost drugs but also health care personnel and systems that can perform reliably at all levels and be accessible to patients. Thus vertical programmes that sidestep the inherent weaknesses of health care systems are not really an option for dealing with chronic diseases. Since 1992, work by Feachem and others has indicated treatment and prevention approaches that could be adapted to developing countries with budget constraints.

From a patient’s perspective, unfamiliarity with the risk factors for chronic diseases and lack of experience in dealing with heart disease or cancer are particularly important. The economic impact of chronic diseases is likely to be even more pronounced than that of communicable diseases, since they typically disable and kill adults of working age. Low-cost but effective approaches to long-term management of chronic conditions need to be developed and implemented.

Neurological and psychiatric disorders lead to only about 1.4% of deaths in low- and middle-income countries (1.8% in high-income countries), but they cause suffering and disability far beyond what the mortality numbers suggest. About 10% of the disease burden in DALYs in low- and middle-income countries results from these conditions, much of it attributable to three major psychiatric diseases: unipolar major depression (3.1% of DALYs), bipolar disorder (0.6%), and schizophrenia (0.8%).

Lowering under-5 mortality

Table 3.1.4 lists the most cost-effective interventions to reduce under-5 mortality and to prevent and treat HIV/AIDS and noncommunicable diseases. Here we discuss interventions to lower under-5 mortality in detail.

Mortality of neonates and children under 5 can be greatly reduced with affordable interventions of proven effectiveness. Improvements can come from increasing coverage of preventive measures, such as breastfeeding, and expanding childhood vaccination programs beyond the traditional six antigens, in places where immunization coverage is already high and where new antigens, particularly pneumococcal and Haemophilus influenzae type B (Hib) vaccines, address diseases of significant burden. Implementation and increased coverage of interventions for acute respiratory infections, malaria, and diarrhoea should reduce the annual 6 million preventable deaths in this age group.

Adding essential care for newborn babies (warmth, cleanliness, and immediate breastfeeding), neonatal resuscitation, facility-based care of preterm babies and emergency care of ill neonates to the standard maternal and child health package has proved highly cost-effective in India ($11–265 per year of life saved, or $24–585 per DALY averted) and sub-Saharan Africa ($25–360 per year of life saved, or $46–657 per DALY averted); however, these interventions require a high initial investment. Addition of community-based interventions—promoting healthy behaviours, such as breastfeeding, providing extra care of moderately small babies at home through cleanliness, warmth, and exclusive breastfeeding, plus management of acute respiratory infections—to the maternal and child health package is likely to be highly cost-effective. A year of life saved could cost as little as $100 to $257 in India ($221–568 per DALY averted) and $100 to $270 in sub-Saharan Africa ($183–493).

Community-based approaches are now feasible in virtually all countries. If a midwife is available, resuscitation of newborns with a $5 self-inflating bag could save lives at low cost in low- and middle-income countries. Provision of two tetanus toxoid immunizations to all pregnant women could avert more than 150 000 neonatal deaths every year. Improvement of maternal- and child-health services delivered through a combination of family-level and community-level care, outreach, and clinical care would increase the survival rates of newborn and older children and reduce stillbirths and maternal deaths.

Childhood vaccinations, long recognized as among the most cost-effective uses of resources, prevented more than 3 million deaths worldwide in 2001. National immunization programs include vaccines against diphtheria, pertussis, and tetanus (DPT); tuberculosis; poliomyelitis; and measles at a cost of $13 to $24 per fully immunized child, depending on coverage levels and delivery strategy (health-facility based, special campaigns like national immunization days, or mobile team outreach). The estimated cost per death averted varies from less than $275 ($10 per DALY averted) in sub-Saharan Africa and South Asia to $1754 ($20 per DALY averted) in Europe and central Asia. The variation is largely attributable to differences in the underlying prevalence of disease. These same factors also affect the cost-effectiveness of scaling up coverage with the traditional Expanded Program on Immunization (EPI) vaccines. The cost per death averted varies by region, from $162 in sub-Saharan Africa to more than $1600 in Eastern Europe. Costs are less than $20 per DALY averted in all regions other than Europe and central Asia. Cost-effectiveness of the tetanus toxoid vaccine also varies widely, from less than $400 per death averted ($14 per DALY averted) in sub-Saharan Africa and South Asia to more than $190 000 ($15 000 per DALY averted) in Europe and central Asia.

Including a second measles vaccination through routine immunizations or special campaigns costs $23 to $228 per death averted and less than $4 per DALY averted in developing regions other than Europe and central Asia. New vaccines cost more per dose and are less cost-effective than the current EPI vaccines but might be worthwhile in regions of high disease prevalence. The pentavalent vaccine (DPT plus hepatitis B and Hib) has an estimated cost of $1433 to $40 000 per death averted and a cost-effectiveness of $42 per DALY averted in sub-Saharan Africa, and more than $245 elsewhere. Addition of a yellow fever vaccine costs between $834 per death averted ($26 per DALY averted) in sub-Saharan Africa and $2810 ($39) in Latin America and the Caribbean.

Multivalent pneumococcal conjugate vaccines could reduce the incidence of invasive pneumococcal disease while lowering antibiotic use and the likelihood of drug resistance. At $50 per dose, however, these vaccines are unaffordable to most people in low- and middle-income countries. After confirmation of efficacy and subsequent licensing, new vaccines that protect against rotavirus, malaria, human papillomavirus (associated with cervical cancer), and dengue could be included in the EPI schedule.

Although more demanding of health system capacity than vaccination, patient treatment is also an efficient use of resources. Management in the community and at a health care facility might be comparably cost-effective, but community-based strategies hold promise for more rapid coverage. Treatment of nonsevere pneumonia at facilities with oral antimicrobials and paracetamol ($24–424 per DALY averted) is slightly more cost-effective than similar treatment administered at home by a health care worker ($139–733). Treatment of severe pneumonia in a hospital is more expensive ($1486–14 719).

Of the interventions for diarrhoeal disease during the first year of life, breastfeeding promotion programmes ($527–2001 per DALY averted), measles immunization ($257–4565), and oral rehydration therapy (as low as $132, for a cost per child of $0.70) are more cost-effective than immunizations for rotavirus ($1402–8357) or cholera ($1658–8274). Lower prices and improved logistics for recently licensed rotavirus vaccines could make this intervention substantially more attractive. Because great reductions in mortality from this condition have already been achieved, the average case fatality rate from diarrhoea is now much lower than before oral rehydration therapy was introduced. Where none of these interventions has been adopted, diarrhoeal disease is still a major killer, and oral rehydration therapy and other measures are more cost-effective in preventing deaths even if diarrhoea incidence is unchanged. The situation is parallel with that for immunization: cost-effectiveness might look poor because of gains already achieved, but both continued and expanded coverage are needed. Similarly, improvements in water and sanitation ($1118–14 901 per DALY averted from diarrhoea) are less cost-effective where access to these amenities is adequate and other interventions against diarrhoea exist. In areas with little access to water and sanitation, however, improvements can be highly cost-effective because they reduce incidence of illness ($94 per DALY averted for installation of hand pumps and $270 per DALY averted for provision and promotion of basic sanitation facilities).