Where You're Born Even Within A Country Still Matters

Better vaccines, nutrition and disease control have cut the global death rate for children in half over the past 20 years. But even within countries that have made major progress, children can face greatly different fates.

"Where you're born substantially impacts your probability of surviving to 5," says Simon Hay, an epidemiologist at the University of Washington who is the lead author of a new study on childhood mortality in Nature.

The research, funded mostly by the Gates Foundation (which is also a funder of NPR and this blog), looks within the borders of 99 low- and middle-income countries that account for 93% of child deaths. Since 2000, those deaths have dropped from some 10 million a year to 5.4 million.

But the study found major differences within countries, confirming that children living in rural areas where health services are limited are often at greater risk of dying young.

In Vietnam, the researchers found the child mortality rate in the rugged mountainous district of Muong Te (40 deaths per thousand live births) to be more than five times higher than the rate in Ho Chi Minh City (7 deaths per thousand live births). Similar differences in magnitude exist within Nigeria, where the rural northern savannas of the Garki Local Government Area hold the highest child mortality rates in the world (nearly 200 deaths per thousand live births), while rates in Egor, a Local Government Area that borders the industrial center Benin City in the southwest, are much lower (around 50 deaths per thousand live births).

The study looked at children under age five, because 85% of childhood deaths are concentrated in those years.

Higher vaccination rates, more consistent access to better food and treatments for diarrhea, pneumonia and malaria, have greatly improved the chances of living for kids ages 1 to 5. For those under 1, the survival rate is lagging — and often related to complications from premature births.

Newborn health is often entwined with women's rights, says Dr. Stefan Baral, an epidemiologist at Johns Hopkins University unaffiliated with the study. "I see the challenges as being not just those of health systems and economic development," he says, "but also women's access to reproductive health services, contraception, safe abortion services.

The study also shows that the number of deaths in an area can be high, even if the death rate is low, simply because of population density.

"In identifying those areas where there's either high rates or high counts of child deaths, I was surprised by what a different picture you could get if you looked at those two different measures," says Aubree Gorden, an epidemiologist at University of Michigan not related to the study. "The interventions you're going to need to be successful are going to be very different" depending on the most pressing causes of child death in an area and the cultural context of how people want to deal with it.

Hay says in rural areas – with high childhood death rates but low populations – deaths are often caused by lack of access to health care. So bringing van services or health-care workers to remote areas could help. In urban slums – where rates are low but death numbers are high – the problem is overcrowding. So improving the local environment, through community toilets or separating animals from people, could more effective at lowering the rates.

An op-ed accompanying the paper in Nature looks at some interventions that worked in Chile. "Our programmes focused on goals far beyond that of making sure that sick children could see a doctor," writes Michelle Bachelet, the UN High Commissioner for Human Rights and former Chilean president. Their roadmap for reducing child mortality included improved access to education through free daycare and preschool for poor families, food security through school meal programs and outreach to indigenous communities in their own languages.

Lessons from neighbors

Sub-Saharan Africa holds the highest death rates but also some remarkable cases of improvement.

"I think it will be very interesting to learn from Rwanda," says Dr. Ramadhani Noor, a Tanzanian health and nutritional specialist with UNICEF in Zanzibar, not affiliated with the study.

Kayonza is Rwanda's worst-performing district today in terms of child death rates, but its childhood mortality rate (57.2 per thousand births) is far better than Rwanda's best-performing district 20 years ago. Much of its success is due to basic investments in the health sector – training more community health workers, improving access to health care.

The major value of this research, says Noor, is that it helps countries like his look for neighboring success stories that can translate.

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