JAMA Pediatrics
March 2016, Vol 170, No. 3
http://archpedi.jamanetwork.com/issue.aspx

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Editorial | March 2016
The Grand Divergence in Global Child Health Confronting Data Requirements in Areas of Conflict and Chronic Political Instability
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Paul H. Wise, MD, MPH1,2; Gary L. Darmstadt, MD, MS1,2
Author Affiliations
1Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
2Freeman Spogli Institute for International Studies, Stanford University, Stanford, California
[Initial text]
There is something deeply troubling about a death that goes unnoticed. Beyond the humane impulse to provide solace through collective acknowledgment and community support lies the recognition that an unnoticed death implies an unnoticed life. There can be no doubt that the accurate counting and causal attribution of morbidity and mortality provide technical information that is essential for public health planning, evaluation, and improvement in program performance. However, there is also a justice imperative inherent in counting and attribution—an imperative that transcends the practical and touches on the moral basis of global health and its commitment to the rights and societal claims of those whose health and well-being have for too long gone unnoticed.

At a global level, available data demonstrate that dramatic reductions in child mortality have occurred in many low- and middle-income countries. Moreover, long-standing disparities in survival between materially wealthy and poorer regions of the world are dissipating. If sustained, this historic record of reduced mortality inequality could drive a “grand convergence” in life expectancy during the next 2 decades.1 This prospect has been used constructively to advocate for a continued global commitment to economic development and the provision of effective health interventions.

On closer examination, however, it is apparent that the trends toward convergence have not been universal. Some countries are being left behind. These countries have experienced stagnant or, in some arenas, worsening child health outcomes. Indeed, these countries could be described as contributing to a “grand divergence” in life expectancies, in which their health indicators fall increasingly behind those of other low- and middle-income countries.2

The article by the Global Burden of Disease (GBD) Pediatrics Collaboration in this issue of JAMA Pediatrics represents an important contribution to the field of global health and provides troubling evidence of the diverging trends in child health and well-being.3 What is now evident from even a cursory examination of presented child mortality trends is that the countries making the least progress in child survival and well-being, particularly since 2000, are those most likely to be plagued by chronic civil conflict, political instability, and weak governance. Nigeria and the Democratic Republic of the Congo, which together account for more than a third of all child deaths in sub-Saharan Africa, experienced annual child mortality declines of 2.2% and 1.8%, respectively (eTable 9 in their Supplement). It is useful to note that during this same period among the most rapid annual declines were those recorded in China (6.01%), Iran (5.97%), and Bangladesh (5.24%).

Using data from the GBD 2013 study, the article presents detailed child mortality and morbidity trends for the 50 countries with the largest child and adolescent populations in the world, information that will prove essential for programmatic evaluation and planning…

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Special Communication
Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study
FREE
Global Burden of Disease Pediatrics Collaboration
Includes: Supplemental Content
Abstract
Importance
The literature focuses on mortality among children younger than 5 years. Comparable information on nonfatal health outcomes among these children and the fatal and nonfatal burden of diseases and injuries among older children and adolescents is scarce.
Objective
To determine levels and trends in the fatal and nonfatal burden of diseases and injuries among younger children (aged Evidence Review
Data from vital registration, verbal autopsy studies, maternal and child death surveillance, and other sources covering 14,244 site-years (ie, years of cause of death data by geography) from 1980 through 2013 were used to estimate cause-specific mortality. Data from 35,620 epidemiological sources were used to estimate the prevalence of the diseases and sequelae in the GBD 2013 study. Cause-specific mortality for most causes was estimated using the Cause of Death Ensemble Model strategy. For some infectious diseases (eg, HIV infection/AIDS, measles, hepatitis B) where the disease process is complex or the cause of death data were insufficient or unavailable, we used natural history models. For most nonfatal health outcomes, DisMod-MR 2.0, a Bayesian metaregression tool, was used to meta-analyze the epidemiological data to generate prevalence estimates.
Findings
Of the 7.7 (95% uncertainty interval [UI], 7.4-8.1) million deaths among children and adolescents globally in 2013, 6.28 million occurred among younger children, 0.48 million among older children, and 0.97 million among adolescents. In 2013, the leading causes of death were lower respiratory tract infections among younger children (905,059 deaths; 95% UI, 810 304-998,125), diarrheal diseases among older children (38,325 deaths; 95% UI, 30,365-47,678), and road injuries among adolescents (115186 deaths; 95% UI, 105 185-124870). Iron deficiency anemia was the leading cause of years lived with disability among children and adolescents, affecting 619 (95% UI, 618-621) million in 2013. Large between-country variations exist in mortality from leading causes among children and adolescents. Countries with rapid declines in all-cause mortality between 1990 and 2013 also experienced large declines in most leading causes of death, whereas countries with the slowest declines had stagnant or increasing trends in the leading causes of death. In 2013, Nigeria had a 12% global share of deaths from lower respiratory tract infections and a 38% global share of deaths from malaria. India had 33% of the world’s deaths from neonatal encephalopathy. Half of the world’s diarrheal deaths among children and adolescents occurred in just 5 countries: India, Democratic Republic of the Congo, Pakistan, Nigeria, and Ethiopia.
Conclusions and Relevance
Understanding the levels and trends of the leading causes of death and disability among children and adolescents is critical to guide investment and inform policies. Monitoring these trends over time is also key to understanding where interventions are having an impact. Proven interventions exist to prevent or treat the leading causes of unnecessary death and disability among children and adolescents. The findings presented here show that these are underused and give guidance to policy makers in countries where more attention is needed.