Overview of the Global Health Issues Facing Children

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CONTRIBUTORS:Sergio Augusto Cabral, MD, MSc,a,band Anna Tereza Soares de Moura, MD, MSPH, PhD,c,d

a_{International Pediatric Association, Geneva, Switzerland;}b_{Estacio Higher}

Education, Rio de Janeiro, Brazil;cEstacio de Sa University–UNESA, Rio de Janeiro, Brazil; andd_{State University of Rio de Janeiro}_–_{UERJ, Rio de Janeiro,}

Brazil

Address correspondence to Sergio Cabral, MD, MSc, Rua Oliveira Rocha 22/101, Rio de Janeiro, Brazil CEP-22461-070. E-mail : sergio.cabral@estacio.br

Accepted for publication Oct 11, 2011 ABBREVIATIONS

MDG—Millennium Development Goals

UNICEF—United Nations International Children’s Emergency Fund WHO—World Health Organization

doi:10.1542/peds.2011-2665

Overview of the Global Health Issues

Facing Children

This ﬁrst Pediatrics Perspectives column on global health joins the monthly rotation with other columns on medical history, graduate medical education, and medical student edu-cation. It makes good sense to add global health to the rotation. After all, the future of our world depends on the health and well-being of all its children. Medical history will be determined by the global health issues facing children today, and surely our education programs must broaden their content to include worldwide issues to meet the demands of future pediatric practice. It has been said by many pediatricians that any disease found on this planet is no farther than a plane ride from your local hospital. Clearly, the world is a very small place for all its inhabitants, and every day, travel continues to bring us closer. Global Health Perspectives will bring issues to the readership that will stimulate our thinking about strategies and initiatives to improve

child health in the broadest context. For our initial column, Drs Cabral and Soares de Moura have traced the recent history of global child health, sharing perspectives that should cause each of us to think about the future of humankind.

Jay E. Berkelhamer, MD

Editor, Global Health Perspectives

Thirty-three years after the Alma-Ata Declaration expressed the need for urgent action to protect and promote the health of all people of the world, signiﬁcant progress has occurred for children’s health.1 In 1978, when it was adopted, 15 million children aged

,5 were dying worldwide every year. This number decreased to 13 million by 1990 and to 9.2 million by 2007, a 27% reduction in the mortality rate of children aged ,5 years (or 5.5 million fewer children dying per year). Such improvement, still far from be-ing satisfactory, was concentrated in

developed countries. More than 80% of the 9.2 million deaths occur in sub-Saharan Africa and South Asia. The combination of high child mortality rates and high fertility rates in sub-Saharan Africa has actually contrib-uted to an increase in the absolute number of deaths in the region by 400 000 per year. Child mortality rates are widely recognized as a reﬂection of the inequity of income distribution around the world.2 In 1990, indus-trialized countries registered a child mortality rate of 9 in 1000 vs 180 in 1000 in sub-Saharan Africa and South Asia (a 20-fold difference). Ten years later, although the rates decreased in both regions (to 6 in 1000 and 175 in 1000, respectively), the gap had actu-ally increased to a 29-fold difference.3

Children die of multiple causes.4Tobacco, the leading preventable cause of death worldwide, contributes to malnutrition and food insecurity, and secondhand smoke exposure contributes to many

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respiratory disease–related deaths in children and other nonsmokers. In countries with higher child mortality rates, 20% of all child deaths occur in theﬁrst 28 days. This share increases to 50% in countries with mortality rates,35 per 1000 live births.5Better neonatal care is inseparable from good maternal health care, and neonatal mortality is still a serious public health problem, even for developed countries. An unfavorable obstetric outcome such as stillbirth, recognized as one of the most common adverse pregnancy out-comes worldwide, leads to a fourfold increase in recurrence and an increased risk to future pregnancy and birth complications that will demand pedi-atric awareness and long-term care.6

The most prevalent diseases currently associated with global child mortality are still diarrhea, pneumonia, malaria, and measles.7 Malnutrition remains an underlying cause in 50% of the deaths of children,5 years.8Diarrhea is caused by multivariate causes, with infection and lack of social infrastruc-ture playing a major role. The imple-mentation of oral rehydration therapy, reaching 80% of the affected children between 1979 and 1995, contributed to a decrease in the number of deaths in children aged 0 to 4 by 3.1 million per year, an impressive 67% decrease in 2 decades.9Additionally, infants who are breastfed have an average sixfold decrease in their risk of dying from diarrhea. Sanitation programs have differing effects on diarrheal morbid-ity but may produce decreases as high as 68% in the incidence of gas-trointestinal diseases.10

Pneumonia prevention and treatment is widely neglected and contributes to a high mortality rate.11It is estimated that 700 000 to 1 million children aged

,5 die of severe pneumococcal infec-tions such as pneumonia, meningitis, and invasive disease. The annual pneumococcal disease incidence varies

greatly, ranging from 188 to more than 6000 per 100 000 children aged ,5. Here again, poverty makes a difference, because the highest incidence rates are in Africa, and the greatest number of cases comes from Southeast Asia. Only 10 countries from these 2 regions contribute to 66% of all pneumococcal cases in the world. Case fatality from pneumococcal meningitis is high in all regions, ranging from 29% in Western Paciﬁc to 73% in Africa.

Prevention is the key strategy to im-prove this situation. Nevertheless, it is still difﬁcult to achieve because most of the more affected countries do not have consistent data to develop action plans or prioritize their scarce ﬁ nan-cial resources to promote immuniza-tion against pneumococcal infecimmuniza-tions. In 2008, none of the African and Asian countries had initiated routine vacci-nation with conjugate vaccine despite evidence that this strategy had been proven effective in 26 high- and middle-income countries that implemented broad immunization campaigns. The Global Alliance for Vaccines and Im-munization, a public-private partner-ship focused on saving children’s lives and protecting people’s health by in-creasing access to immunization in poor countries, has been providing low-cost vaccines that it is hoped will change this situation. The World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) policies for community-based treatment and enhancement of quality care in hospitals are also playing an im-portant role in reducing child mortality.

In 2000, 189 countries endorsed the UN Millennium Declaration, setting 8 goals to be achieved by 2015, known as the Millennium Development Goals (MDG), committing to eradicate extreme pov-erty and promote a better life to people worldwide.8,12 All 8 MDGs relate in some way to maternal, neonatal, and child needs, but MDGs 4 and 5 have a

speciﬁc focus on these groups. MDG 4 is targeted to reduce mortality of children aged ,5 years by two-thirds, and MDG 5 calls for reducing the maternal mortality ratio by three-quarters and achieving universal access to reproductive health. Despite this global effort to improve child survival, many countries, especially those with very low Gross National Income, do not seem to be on track to achieve the goals in time.

To provide support and monitor the performance of countries with the greatest needs, 3 leading maternal, newborn, and child health alliances (Partnership for Safe Motherhood and Newborn Health, hosted by the WHO; the Healthy Newborn Partnership, based at Save the Children and the Child Survival Partnership, hosted by UNICEF), joined forces in 2005, under the name of the Partnership for Ma-ternal, Newborn and Child Health. As a result of these efforts, maternal, neo-natal, and child health is now a top item on the global health agenda. Addi-tionally, the recent UN noncommunicable disease summit emphasized the need to prevent cardiovascular diseases, can-cers, chronic respiratory diseases, and diabetes and recognized the importance of inclusion of noncommunicable disease prevention and control within maternal and child health programs, especially at the primary health care level.13

Pediatric societies have also a prominent and leading role to play in the battle to improve child survival. The International Pediatric Association, a federation of 166 members (regional, national, and pedi-atric specialty societies), is permanently engaged in the promotion of health and the prevention and treatment of diseases of children, working closely with the major partners in global health, such as the WHO; UNICEF; World Bank; Partnership for Maternal, Newborn and Child Health; International Federation of Gynecology and Obstetrics; Global Alliance for Vac-cines and Immunization; and others.

2 CABRAL and SOARES DE MOURA

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Working within their professional or-ganizations and with local communities, pediatricians are the ultimate group to advocate for better care for children and for appropriate training for front-line health care workers.14 They have the essential skills to prevent and treat these diseases but must also speak out on behalf of children’s full protection and their right to a healthy life. To fulﬁll this mandate, they should be trained in child advocacy during their undergrad-uate and postgradundergrad-uate studies. They must be aware of chronic and acute situations of risk, identifying strategies and the people with real authority to make decisions.

Health care reforms need strong social support to be implemented, and rapid progress can be achieved only if one sends the right message in the right language to the right people. These goals may be tough and complex to tackle, but saving children’s lives al-ways will be worthwhile.

References

1. Loaiza E, Wardlaw T, Salama P. Child mor-tality 30 years after the Alma-Ata Declara-tion.Lancet. 2008;372(9642):874–876

2. Gayle HD, Daulaire N. A better future for women and children.Lancet. 2007;370(9595): 1297–1298

3. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year?

Lancet. 2003;361(9376):2226–2234

4. Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children.Lancet. 2005;365(9465):1147– 1152

5. Oestergaard MZ, Inoue M, Yoshida S, et al; on behalf of the United Nations Inter-agency Group for Child Mortality Estima-tion and the Child Health Epidemiology Reference Group. Neonatal mortality lev-els for 193 countries in 2009 with trends since 1990: a systematic analysis of prog-ress, projections and priorities.PLoS Med. 2011;8(8):e1001080

6. Serour GI, Cabral SA, Lynch B. Stillbirths: the professional organisations’perspective.

Lancet. 2011;377(9776):1471–1472

7. Byass P, Ghebreyesus TA. Making the world’s children count.Lancet. 2005;365(9465):1114– 1116

8. Edejer TT, Moses A, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries.BMJ. 2005;331:1177

9. Pierce NF. How much has ORT reduced child mortality?J Health Popul Nutr. 2001;19(1): 1–3

10. Root GPM. Sanitation, community environ-ments, and childhood diarrhoea in rural Zimbabwe.J Health Popul Nutr. 2001;19(2): 73–82

11. O’Brien KL, Wolfson LJ, Watt JP, et al; Hib and Pneumococcal Global Burden of Dis-ease Study Team. Burden of disDis-ease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates.Lancet. 2009;374(9693):893–902

12. Veneman AM. Achieving millennium devel-opment goal 4.Lancet. 2006;368(9541):1044– 1047

13. United Nations General Assembly. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Available at: www.un.org/ga/search/view_ doc.asp?symbol5A/66/L.1 Accessed Sep-tember 16, 2011

14. Waterston T, Haroon S. Advocacy and the paediatrician.Pediatrics and Child Health. 2008;18(5):213–218

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose.

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DOI: 10.1542/peds.2011-2665 originally published online December 19, 2011;

2012;129;1

Pediatrics

Sergio Augusto Cabral, Anna Tereza Soares de Moura and Jay E. Berkelhamer

Overview of the Global Health Issues Facing Children

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