CHAPTER 9

Global Child Health

Suzinne Pak-Gorstein, MD, PhD, MPH, FAAP, and Maneesh Batra, MD, MPH

Background

Worldwide, an estimated 5.3 million children younger than 5 years of age died in 2018, for an average of nearly 15,000 children dying each day (Figure 9.1). This represents a 58% reduction from the 12.6 million deaths of children younger than 5 years of age estimated in 1990. Even so, significant disparities in child mortality persist and have become increasingly concentrated geographically, with specific regions of the world bearing a disproportionate burden. The continents of Africa and Asia combined account for 86% of all child deaths, with one-third of these deaths occurring in South Asia and half in sub-Saharan Africa. Less than 1% of deaths occur in high-income countries.

Nearly one-third of all child deaths worldwide were caused by 3 communicable diseases: pneumonia (16%), diarrhea (8%), and malaria (5%). Most of these lives could be saved through increased access to low-cost prevention and treatment measures, including antibiotics for acute respiratory infections, oral rehydration therapy for diarrhea, immunizations to protect against pneumococcal pneumonia and diarrhea caused by rotavirus gastroenteritis, and the use of insecticidetreated mosquito nets and appropriate drugs for malaria.

Figure 9.1. Mortality rates for children younger than 5 years in 2018.

Reprinted with permission from United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2019. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York, NY: United Nations Children’s Fund; 2019.

Undernutrition is an underlying cause of at least one-third of all deaths in children younger than 5 years. Reducing chronic and acute undernutrition would have a substantial effect on reducing child mortality. Furthermore, improved coverage of specific nutritional interventions, such as early and exclusive breastfeeding, are cost-effective and reduce the prevalence of pneumonia and diarrhea.

The first month after birth is a perilous phase for a child’s survival, with an estimated 47% of deaths in children younger than 5 years occurring during this period. Most of these deaths occur at home in the first postnatal week as the result of preterm birth (18%); intrapartum-related complications, such as birth asphyxia (12%); and neonatal sepsis (7%). Thus, improving neonatal care is essential to the goal of improving child health. Increased access to basic, inexpensive interventions is necessary to reduce neonatal mortality rates globally, including delivery by skilled birth attendants, hygienic umbilical cord care, and the training of community health workers to assess and begin early treatment for neonatal infections.

Mortality among young children aged 5 through 14 years is lower than that of children younger than 5 years (7.2 deaths per 1,000 live births and 39 deaths per 1,000 live births, respectively). Decreases in mortality for these older children and adolescents have slowed since the year 2000, however. In 2017 an estimated 0.9 million children 5 through 14 years died, which represents approximately 2,465 deaths each day. Most deaths among these children occurred in sub-Saharan Africa (54%) and Southern Asia (25%). Injuries accounted for a larger proportion of deaths (30%) among these older children than among children younger than 5 years, with drowning and road injuries causing 14% of deaths in the older age group. Leading causes of death among adolescents ages 10 through 19 years include road injury, HIV, suicide, lower respiratory infections, and interpersonal violence.

Sustainable Development Goals

In 2015, world leaders agreed to the 17 Sustainable Development Goals (SDGs) for improving global well-being by 2030. The SDGs were built on lessons learned from the 8 Millennium Development Goals (MDGs), which were specific, measurable targets set by the United Nations in 2000 to eradicate poverty, hunger, illiteracy, and disease by 2015. Progress toward meeting the MDGs has been significant, although uneven, with the poorest and most disadvantaged countries as well as marginalized communities and social groups within developed countries not attaining these goals.

The SDGs aim to address the underlying determinants of poverty and poor health in a sustainable manner by expanding its goals to address the systems-based, underlying socioeconomic, political, and environmental factors. The 17 interconnected SDGs are comprehensive and apply universally to all nations, both developed and developing (Box 9.1).

^a These goals were developed and signed by all United Nations member countries in 2015. There are 17 goals with 169 targets (with 1 specific goal for health that includes 13 health goal targets) and a series of measurable indicators for each target.

The third SDG (SDG-3) specifically focuses on population health, to “ensure healthy lives and promote well-being for all at all ages.” Although the MDGs included targeted relative reductions in mortality (eg, reduce under-5 mortality by two-thirds), the SDG-3 sets absolute targets to end preventable deaths of neonates in particular and other children younger than 5 years of age. Specifically, these more equitable goals call on all countries to reduce neonatal mortality to no more than 12 deaths per 1,000 live births and under-5 mortality to no more than 25 deaths per 1,000 live births by 2030.

Inequities in Health

Significant disparities exist in child health. Sub-Saharan Africa grapples with a high child mortality rate (ie, 76 per 1,000 live births in 2017); that is, 1 in 13 children in that region dies before 5 years of age. In comparison, Western European countries have an under-5-year mortality rate of 4 deaths per 1,000 live births, and in high-income countries fewer than 5 per 1,000 children die before their fifth birthday.

In 2017, an estimated 82% of all the growth in global wealth went to the top 1%, whereas the bottom 50% saw no increase at all. The SDG-10 calls for reducing inequalities in income as well as those based on age, sex, disability, race, ethnicity, religion, or other status within a country. Large inequalities in child health exist between, as well as within, countries. For example, in Bolivia and Peru, the richest one-fifth of the population has almost universal access to a skilled attendant at birth, compared with only 10% to 15% among the poorest one-fifth. Women in poor rural households accounted for two-thirds of unattended births.

Although the United States spends more on health than any other country ($10,348 per capita), it ranks lower than other highly developed nations with respect to its under-5 mortality rate (7 deaths per 1,000 live births), which is greater than rates in most of Europe. Additionally, the United States lags behind other comparable countries with worse life expectancy and higher rates of disease burden as calculated in disability-adjusted life-years. Significant health inequities are also apparent within the United States. Black children age 1 to 4 years have the highest death rates (38.8 per 100,000), followed by Native American children (30.5 per 100,000); Asian/Pacific Islander children have the lowest death rates (16.5 per 100,000). Much of the differences in health outcome are the result of disparities in nonmedical social determinants, such as income and education. Compared with other Western countries, however, the United States spends disproportionately more on health care than on social services that could indirectly improve health outcomes.

To attain the SDGs of reducing child mortality, targeted interventions that focus on the poorest populations are needed that could close gaps in intranational health disparities. It has been projected that policy interventions aimed at reducing country-level inequities would have a major effect on the under-5 mortality rate. Worldwide, had the child mortality rates of all countries been reduced to that with the lowest rate (2.1 deaths per 1,000 live births), a total of 5.1 million deaths of under-5 children could have been prevented in the year 2017 alone, which would represent a 95% reduction of child deaths.

The Health and Medicine division of the National Academies (formerly the Institute of Medicine) definition of global health (GH) encompasses “health problems, issues, and concerns that transcend national boundaries, and may best be addressed by cooperative actions….” For the World Health Organization, GH involves health problems that affect global politics and economies and arise from disparities in sociopolitical and economic status. Inequalities in health within and between countries arise from inequalities within and between societies. Consequently, the emerging field of GH intersects medical and social science disciplines such as demographics, economics, epidemiology, political economy, and sociology.

Integrating Global Health Into Pediatric Careers

Children constitute the most vulnerable group in any society, and the strongest medical advocate for the health of children is the pediatrician. Consequently, pediatricians have been leaders in addressing global and local health disparities, and their collective voice has been powerful. Global health work varies widely in scope and extent. The duration of GH activities ranges from single short-term medical missions to long-term postings in resource-limited settings. Involvement in GH encompasses the direct provision of clinical services, technical assistance for program development, research, education and training of health workers, and governmental advocacy for policy changes. The goals of GH activities range from forging novel directions in areas of basic science and epidemiologic, clinical, and operations research to addressing the needs of the world’s poorest communities. Ideally, GH experiences should be transformative for the health professionals who engage in these experiences and for the poor communities of the world that they serve.

By committing to a single international site (eg, hospital, rural clinic, community) and working with a partner based at that site, the pediatrician can engage in a longitudinal supportive relationship that is sustainable and effective. Pediatricians can also make a sustainable impression by empowering in-country partners through training of trainers, such as community health workers, supervisors, and clinicians responsible for health professional trainees.

Pediatricians may engage in GH activities in multiple domains, including patient care, teaching and training, research, and advocacy. Pediatricians have also played an important role in responding to humanitarian emergencies in the United States as well as in other countries, such as in the aftermath of devastating earthquakes and other natural disasters. Additionally, pediatricians with skills in research and evaluation may contribute to GH through clinical research and program evaluations.

Many GH opportunities do not require an overseas trip. Although vulnerable populations and health inequities certainly exist in low-income countries, significant inequities abound in the United States. Among developed countries, those with the highest health status have the lowest levels of health inequality. The United States ranks at the bottom of this list, with 1 of the poorest health rankings and the highest inequalities in health. Opportunities to engage in local GH work are plentiful and include supporting the care and resettlement of local refugee and immigrant families, supporting international adoptees, serving migrant farmworkers, and supporting Native American health issues.

The pediatrician may also work locally for GH by advocating for equity of health care at all levels domestically and globally, working in the home office of a US-based GH organization, and providing expertise to support international organizations dedicated to helping vulnerable children. Finally, pediatricians can make a significant impact in GH by lobbying the US government for more international relief funding or supporting corporations with ethical international trade practices.

Beyond the Hospitals: Global Health, Community Health, and Advocacy

Increasing numbers of medical students and residents in the United States seek training opportunities in developing countries, and most of these trips are spent in a foreign hospital on a pediatric ward providing direct clinical care. In addition to observing and managing tropical diseases and more severe forms of commonly encountered pediatric conditions, visiting physicians and students learn and experience common themes in these low-resource settings: underpaid and undertrained health workers, hospital administration untrained in health management, dilapidated facilities, basic medicine shortage, lack of tools in testing and imaging, and higher mortality rates. Because the needs at such hospitals and clinics are glaring, the physician instinctively seeks to fill the gaps with what defines quality health care in the United States— more medicines, equipment, clinical staffing (in the form of visiting physicians), and perhaps training. However, the long-term effect of a brief visit, even repeated visits, may be further improved through efforts to prevent disease using public health approaches and focusing on communities.

With additional training in areas such as public and community health or health service management, the pediatrician may act as an “agent of change” by undertaking systems-based quality improvement approaches, public health measures, and community-based strategies to bring about lasting positive effects on child health.

Box 9.2 lists some key categories of GH organizations. In collaboration with community groups, the clinician or student can effectively empower community health workers and work within local community-based nongovernmental organizations (NGOs) to contribute to lasting and contextually appropriate change.

Getting a sense of how most of the world lives is a tremendous gift, honor, and burden that accompanies these experiences. Continuing to advocate for children living in poverty throughout the world after returning from a short-term medical experience is a great way to enact one’s ongoing responsibility. Additionally, although perhaps less glamorous than traveling overseas, working within the US health care and political system to promote awareness for change has the potential to catalyze lasting and significant improvements in child health. Similarly, through work to empower local refugee communities in the United States or to advocate for more equitable access to health care for vulnerable immigrant children, pediatricians can make a significant and lasting difference in the efforts to close the gap in health disparities.

Ethical Issues in Global Health

The traditional model for medical experiences for US-based physicians presumes that individuals in the United States possess the knowledge, skills, and resources to improve the conditions of people living in developing countries. Most students and physicians who have participated in such an experience, however, report that they themselves derive the greatest benefit from such experiences.

Although the desire to improve the conditions of children by providing clinical care is well-intentioned and altruistic, the potential exists for short- and long-term harm. In the short term, caring for children in such settings with conditions that are unfamiliar to visiting students or physicians and out of the scope of their training can result in errors in diagnosis and management. Often, students have less supervision of their clinical work in these settings, which can result in harm to patients and students’ growth as physicians. In the long term, provision of clinical care by visiting students or physicians can undermine the existing health system infrastructure.

Stay updated, free articles. Join our Telegram channel

Join