Cuba and the United States have similar child survival figures despite the fact that the United States has more than 20 times the per capita income. Likewise Chile, Brazil, and South Africa have similar per capita gross national income, but there are significant differences in child survival. There are also clear continental differences, with countries in sub-Saharan Africa falling largely in the category of high mortality and very low gross national income per capita (approximately 50% of the least developed countries in the world are found in sub-Saharan Africa), whereas European countries are largely in the low mortality and high gross national income grouping (with exceptions such as Turkey, Georgia, and Ukraine).

Reproduced with permission. © 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan). Gapminder world chart 2006. Worldmapper Web site. http://www.worldmapper.org.

The Reality

Of the approximately 8 million children who die younger than 5 years of age, about 65% die of infectious causes, with pneumonia, diarrhea, and malaria being the leading causes.⁴ Each of those conditions can be addressed by measures that decrease the incidence and provide effective therapy at an early stage of the condition and subsequently by more complex and expensive approaches that provide effective therapy at an advanced stage of the condition, as outlined in the following.

Acute Severe Pneumonia

Acute severe pneumonia is a major cause of death, with some 1.4 million children dying annually. Multiple factors contribute to this including HIV infection, malnutrition, and exposure to indoor air pollution.⁵ Major reductions in the incidence of pneumonia can be achieved by interventions aimed at reducing acute respiratory infections, such as vitamin A supplementation; prophylactic administration of cotrimoxazole⁶ and isoniazid^7,8 to HIV-infected children; and administration of Hib and pneumococcal vaccination.⁹ Significant reductions in mortality and morbidity from pneumonia can be achieved by interventions such as early treatment with antibiotics and availability of oxygen.¹⁰ Approaches to increasing the availability of oxygen and antibiotics may range from village-based systems where traditional birth attendants¹¹ and village healthcare workers are provided with supplies of cotrimoxazole¹² to facility-based programs that optimize oxygen use. Recent studies have suggested that availability of injectable antibiotics may be associated with improvements in outcomes.¹³

Malaria

Malaria remains one of the biggest killers across the world, and control has not been established in most of the poor countries, with 58% of all cases occurring in the poorest 20% of the world’s population.¹⁴ In cluster studies performed in Africa, only 53% of febrile children in areas with high rates of malaria were receiving antimalarial therapy, and of those, 84% were receiving chloroquine in the presence of widespread resistance to the drug.¹⁴ Insecticide-treated mosquito nets were available to fewer than 2% of children under 5 years of age. Although provision of insecticide-treated mosquito nets can reduce the mortality and morbidity of children younger than 5 years by 17% to 43%,¹⁵ the need to direct programs at the whole population has been highlighted.

Recent studies have highlighted the importance of malaria research in endemic areas where the intensive management used in resource-poor areas may not be beneficial and likely is harmful.¹⁶

Gastroenteritis

The approach to the management of diarrhea starts with provision of clean water; subsequent components include access to and training in the use of oral rehydration fluids; possible administration of rotavirus vaccines; and access to primary and secondary healthcare services. Persistent diarrhea has significant mortality and requires more specialized services for management. Acute hypovolemic shock could respond to relatively simple therapy with intravenous fluids.

HIV/AIDS

Diseases such as HIV and AIDS are major contributors to pediatric mortality, particularly in sub-Saharan Africa. The advent of HIV has threatened advances in child health that have been made over the last few decades¹⁷ and has had a massive impact on admissions to pediatric wards in South Africa.¹⁸ In a study at Barag-wanath Hospital in Johannesburg, total annual pediatric admissions increased by 23.6% between 1992 and 1996, and there was a 42% increase in hospital mortality—from 4.3% to 6.1%—over the same period.¹⁷

Nutrition

Although many children die from severe malnutrition, malnutrition as a contributing factor to other diseases is a major problem and may be a factor in as many as 60% of pediatric deaths across the world. The fundamental causes of this problem are poverty and inequity, and in countries where economies have stabilized and grown, severe malnutrition has largely disappeared. A number of targeted nutritional interventions such as supplementation with zinc and vitamin A have been shown to reduce morbidity and mortality at low cost, although some recent studies have cast some doubt on the efficacy of zinc supplementation.^18,19 Recent work has reemphasized that survival from severe acute malnutrition can be substantially improved with low-cost intervention.²⁰

Neonatal Deaths

Neonatal deaths are a major component of infant mortality in the developing world. Baqui et al²¹ reported that in a review of 1,048 perinatal deaths, there were 430 (41%) stillbirths and 618 infants who died following live birth. Thirty-two percent, 50%, and 71% of deaths occurred within 24 hours, 3 days, and 7 days of birth, respectively. In the first week of life, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Fifty percent of deaths attributable to sepsis or pneumonia occurred during the first week of life, whereas the deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. Many of these deaths could be prevented by access to effective therapy for hypoglycemia, hypoxemia, and shock, such as could be provided in an area that offers basic critical care.

Trauma

Industrialization in the developing world has increased the burden of traumatic disease. Moreover, it is likely that the burden of trauma is significantly underestimated, because trauma registries, which are known to improve injury surveillance in order to enhance trauma care outcomes and prevention, are sorely lacking in many of these resource-poor settings.²² Data from Chennai, India, reveal increasing mortality from trauma, with half of trauma victims having no prehospital intervention.²³ Other data from India show that it has the highest incidence of injuries per 100,000 vehicles in the world,²⁴ and in 2005 the British Broadcasting Corporation reported that every 6 minutes 1 person dies and 10 are injured in India.²⁵

Congenital Disease

While the majority of pediatric deaths in poorer countries are related to infectious disease and trauma, the burden of congenital abnormalities is no lower in the poorer countries (and may even be higher as there are very limited prenatal diagnostic services), but there is a great deficit of curative and supportive services for these conditions.

In the developing world, rheumatic heart disease is often seen as the major pediatric cardiac surgical problem, and many children die from this disease. Surgical intervention can significantly prolong life (and, perhaps more important, improve quality of life), but survival after surgery for rheumatic heart disease is deeply dependent on the quality of supportive medical services. Children with congenital heart defects such as ventricular or atrial septal defects may have essentially normal life expectancy with minimal medical follow-up and may represent a better expenditure of health resources. However, reviews of access to pediatric cardiac surgery in regions such as Africa show that most children on the continent have essentially no access to pediatric cardiac surgery.²⁶

Resources

In many of the countries with the least resources (and often the highest burden of disease), healthcare resources are limited for many reasons, including financial constraints, lack of trained personnel, deficiencies in basic infrastructure (water, electricity, transport networks, buildings), and political instability (and corruption in many cases).³

Primary care including immunizations and good nutrition should be the foundation of any healthcare system. However, in many parts of the world, children simply do not have access to healthcare facilities within walking distance of home. The majority of clinics that are available have minimal resources for emergency care (either trained personnel or equipment). In many of the poorest countries of the world, families are required to make a financial contribution to healthcare, and this limits access.³

Very significant changes in neonatal mortality can be achieved without recourse to critical care services. Community-based interventions to improve perinatal and neonatal health outcomes in developing countries were extensively reviewed by Bhutta et al.²⁷ It was clear that improved neonatal outcomes were integrally associated with improved maternal care. Interventions in the training of traditional birth attendants and village healthcare workers,^28,29 together with innovations such as access to bag–mask ventilation^5,28-37 or antibiotics such as cotrimoxazole, have been shown to have profound effects on the mortality of neonates, including low-birth-weight and preterm infants, in India and Bangladesh at remarkably low cost. Access to low-technology solutions for care of premature infants, such as “kangaroo care,” may have a profound impact on the outcomes of prematurity across the world, although this is still open to debate.^38-42

Prehospital Care and Transport Services

The development of emergency medicine responses at the level of prehospital care in northern Iraq and Cambodia was associated with a significant decrease in mortality after laypeople were trained to work as lay responders.^43,44 In many cases, these children need definitive care. On the basis of current guidelines, it has been estimated that 10% to 20% of children who present at community clinics with acute illness will require referral to other levels of care.⁴⁵ Provision of appropriate referral structures and transport systems is thus essential.

In the poorer countries, transport facilities for healthcare may be extremely limited. For instance, in Tanzania critical care transport is performed by bicycles with trailers, tricycles with platforms, motor boats, and ox carts,⁴⁶ whereas in Ghana, taxis and buses are primarily used, and taxi drivers receive prehospital training for emergency procedures.⁴⁷ The lack of transport, long distances, and high transportation costs lead to significant delays in getting to a hospital.^48-50 Data from Uganda⁵¹ indicated that families would not complete referral of children to hospitals because of financial constraints but also because of the perception that the hospital lacked the resources (personnel and material) to provide the care that the children required.

Medication and Equipment

In many cases essential medicines on the World Health Organization (WHO) list can be purchased, but most are not immediately available, and fake or low-quality drugs still pose a major problem.^52-54 Oxygen is expensive and not widely available; mechanical ventilation is done sporadically and is associated with high mortality rates (58%-74%).^55,56 Basic equipment, such as ventilators and monitors, is of lower quality than that used in the first ICUs in Europe in the 1950s. Indeed, stethoscopes and sphygmomanometers are the only monitoring devices in many institutions and in most hospitals in Uganda.^57,58

Hospital-Based Emergency and Critical Care

There is evidence that a substantial proportion of children presenting to hospitals for care across the world receive suboptimal care.^59,60 A study of pediatric care in 14 hospitals in Kenya demonstrated that more than half of the children were inappropriately or inadequately treated with antibiotics, fluids, and oxygen.⁶¹ Similar data come from Angola, Brazil, Cambodia, Indonesia, and beyond.⁶²

There is also evidence that major improvements in pediatric trauma care can be achieved by reorganization and review of systems.^63-68

Campbell et al⁴⁵

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