Caring for the kids.

With millions of young people still dying unnecessarily each year, renewed efforts are required to provide better healthcare, services and environments for children.

In many ways, the world has made huge progress on improving children’s health in recent decades.  A sustained focus on the survival of children under five has led to deaths among that age group plummeting.  Since 1990, the global under-five mortality rate has dropped by 60%, from 93 deaths per 1000 live births in 1990 to 37 in 2022, according to a report from the United Nations Children’s Fund (Unicef) published this year.  And in the most recent data, annual under-five deaths reached a historic low, falling to 4.9 million.[1]

But Unicef says that despite the significant progress seen, the death toll among children and young people remains unacceptably high.  Its report highlights that in addition to under-five deaths, there were a further 2.1 million deaths among children and young people aged between five and 24.  Between 2000 and 2022, the world lost 221 million children, adolescents and youths in total – equivalent to almost the entire population of Nigeria.  So while recognizing this “noteworthy moment”, Unicef stresses that threats to the health and survival of children persist globally, particularly among the most marginalized people.

Worryingly, key indicators suggest that progress is stalling.  Between 2015 and 2022, the global mortality rate for under-fives fell almost half as quickly as it did between 2000 to 2015[2].  A further concern is that deaths are falling more slowly among newborn babies (first 28 days after birth), since these account for almost half of under-five deaths globally.  The neonatal mortality rate has stagnated in sub-Saharan Africa – the region that accounts for the majority of such deaths.  And Unicef says that if current trends continue, 59 countries will not meet the under-five mortality target under the UN’s Sustainable Development Goals (SDG) on time (SDG target 3.2), and 64 countries will fall short of the mortality target for newborn children.[3]

Unicef concludes “there is still a long road ahead to end all preventable child and youth deaths”.  And of course, children’s health is not only about survival, but supporting overall wellbeing.  The World Health Organization (WHO) says that “child health, growth and development are inseparable”.  The organization warns that in 2016, at least 250 million children were not able to reach their full physical or psychological development, and that “no country is currently providing the conditions needed to support every child to grow up and have a healthy future”.[4]  It’s clear that significant challenges still remain in supporting and improving children’s health worldwide.

Source: Unicef

New challenges

The UN says that for newborn babies, premature birth and complications during labor are the leading causes of death.  Meanwhile, for children that survive the first 28 days, the biggest threat comes from infectious diseases including malaria, pneumonia, and diarrhea[5] (which together accounted for about 30% of global under-five deaths in 2019[6]).  According to the WHO, many child deaths can be prevented through measures such as vaccination, home care, and better access to health care[7].  Specific interventions highlighted in Unicef’s report include skilled health personnel attending births, care for small and sick newborns, and more community health workers – and the agency emphasizes the importance of reducing risk factors such as malnutrition.  The report praises the commitment of governments, organizations, local communities, healthcare professionals and familiesfor the improvements of recent decades.  But it adds that “decisive and urgent investments” will be needed to meet the UN’s SDG targets.

Emerging issues are adding further difficulties.  In 2020, a commission of 40 experts convened by the WHO, Unicef and The Lancet journal (The Lancet commission) warned in a major report that new challenges were “escalating at such speed as to threaten the progress and successes of the past two decades”.  In particular, it said the climate emergency was making a future world that could support children’s wellbeing less likely, while commercial exploitation was encouraging “harmful and addictive activities” that were damaging young people’s health.  Ecological degradation, migration, conflict, and inequality were also named as important factors.

Environmental factors

The Lancet commission’s report[8] argues that climate change presents profound and imminent threats to global health, with the consequences of not meeting sustainability goals falling on children and young people.  It notes that climate disruption is creating “extreme risks” from factors such as food and water insecurity, extreme weather, heat stress, and emerging infectious diseases.  More than 2 billion people, says the commission, live in countries where development (and therefore health outcomes) is affected by political fragility and conflict – problems that are increasingly connected to global warming.  In 2018, 40 million people, including many children, were displaced by conflict, natural disasters, or climate change – a figure that is likely to have increased significantly in recent years to reflect increasing global geopolitical uncertainty.  The report points out that children are the most vulnerable to the long-term environmental effects of climate change, as well as from environmental pollution linked to industry.

Changing weather patterns are impacting efforts to tackle diseases that are major causes of child deaths.  A report published this year from the African Leaders Malaria Alliance (ALMA) – consisting of 55 heads of state and government – says that climate change “presents a major threat to health and the fight against malaria”.  Not only will more frequent natural disasters damage infrastructure and displace populations, but higher temperatures and higher rainfall will lead to increased transmission, it warns.  The report points to the impact of Cyclone Freddy, for example – the strongest and longest-lasting tropical cyclone ever recorded, which hit several countries in southern Africa in 2023, killing more than 1,200 people in Malawi.[9]  ALMA highlights how the storm damaged or destroyed hundreds of health facilities and left populations unprotected against mosquitoes.  Meanwhile, washed out roads and infrastructure made it more difficult to restore services.  “Without urgent action, malaria cases and deaths, as well as neglected tropical diseases, will become the face of climate change and health,” says the report.

Similarly, researchers believe that climate change threatens recent progress made in tackling diarrheal diseases.  A study from the University of Surrey found that higher temperatures and humidity were both linked with the increased spread of campylobacteriosis, a bacterial infection which can cause diarrhea[10].  And climate events such as sudden heavy rain can make sewers overflow, contaminating water supplies[11].

In addition to climate change, a separate Lancet article in 2022 emphasized that air pollution and toxic chemicals also present serious risks to children’s health[12].  Prenatal exposure to these environmental hazards can increase the risk of disease in a child and impact their health for the rest of their life.  In fact, research by the WHO in 2017 said that about a quarter of childhood deaths (26%), and of the total disease burden in children under five (25%), could be prevented by reducing environmental risks such as air pollution, unsafe water, inadequate hygiene and chemicals.[13]

A 2022 report from Unicef[14] says that in Europe, polluted air “contributes to more deaths than tobacco”.  And it highlights how children are more vulnerable to air pollution, due to factors including smaller lungs and less developed immune systems.  Of the 43 countries that are members of the Organization for Economic Co-operation and Development (OECD) and/or the European Union (EU), those with the highest numbers of healthy life years lost due to air pollution were found to be Colombia (3.7) and Mexico (3.7).

Unicef’s report also describes chemical pollution as being “among the largest threats to child health and development worldwide”.  The prevalence of some well-known pollutants is concerning.  Lead, for example, is a neurological and cardiovascular toxicant that can cause a wide range of harms, such as impacting children’s bodily functions, attention spans, memory and cognitive functioning.  The report says that in nine OECD/EU countries, more than one child in 20 is being poisoned by lead – with 13.4% of children in Costa Rica, and 31.1% of those in Mexico, having elevated levels in their blood.  Worryingly, the metal can cause harm even at very low concentrations. In addition, in most of this group of countries, more than one child in 20 lives in an area of high pesticide risk.  In both Poland and Czechia, for example, more than 9% of children under 18 live in areas with a high pesticide pollution risk.  Pesticide pollution has also been linked with a wide range of harms, including damage to children’s nervous, cardiovascular, digestive, reproductive, and immune systems.

Modern lifestyles and environments mean that exposure to environmental toxins is considerable.  Unesco says that through polluted air, water and food, for example, we each inadvertently consume a quarter of a kilogram of plastic per year.  Children’s still-developing bodies and risk-increasing behaviors (such as putting their fingers in their mouths) make them particularly vulnerable.  And yet of the more than 140,000 chemicals and pesticides developed since the 1950s, the majority have never been tested for toxic effects on the developing brain.  Toxins can impact children before they are born through the exposure of pregnant women.  A study based on 3,500 mother-child pairs found that elevated maternal levels of chemicals such as phthalates, toxic metals and plastic toxicants were associated with effects such as a reduction in cognitive functions and an increased risk of ADHD and autistic spectrum disorder in the children.[15]

The rapid growth of electronic waste (e-waste), such as computers, mobile phones and household appliances, is exacerbating the risks from chemicals.  E-waste contains various toxins, such as lead and mercury, that can harm children’s health – such as the development of their nervous systems and lungs.[16]  In 2022, a record 62 million tons of e-waste were produced – 82% higher than in 2010.[17]  The amount is set to increase by a further third by 2030 – meaning the proportion of this waste that is satisfactorily processed is likely to drop, as the growing amount outstrips documented recycling efforts.  Given this deficit, the informal processing of e-waste is a significant factor putting the health of children at risk.

A report from the WHO in 2021 said that more than 18 million children were working in the informal industrial sector – of which waste processing is a sub-sector.[18]  Children’s small and dexterous hands mean they can be seen as suited to dismantling electronics, the report says. And indeed, many children are involved in waste processing from a young age.  The Associated Chambers of Commerce and Industry of India has previously found that about 45,000 children between the ages of 10 and 14 were working in the informal recycling sector in Delhi[19].  There is little data on the proportion of such work that specifically involves e-waste. But the International Labor Organization (ILO) found that at an e-waste site in Ghana, children between 11 and 18, and at sometimes as young as five, were involved[20].  In addition, other children are put at risk by living, attending school or playing near e-waste recycling centers.  The WHO’s findings prompted its director-general, Dr Tedros Adhanom Ghebreyesus, to call for global efforts to protect children’s health from the “growing threat” of e-waste.[21]

Harmful marketing

In The Lancet commission’s report in 2020, another factor highlighted as detrimental to children’s health was “harmful commercial marketing” which promotes addictive substances and unhealthy commodities, such as junk food and sugary drinks.[22]  These “predatory” practices are linked to obesity, which increased 11-fold between 1975 and 2016 – from 11 million to 124 million.  The promotion of alcohol and tobacco is also a concern: in the US, youth exposure to television e-cigarette advertisements rose by 256% between 2011 and 2013.  One of the commission’s authors said that despite industries signing up to self-regulation in Australia, children and adolescent viewers were exposed to 51 million alcohol ads during just one year of televised football, cricket and rugby – adding that due to a lack of data on social media advertising, the reality could be “much worse still”.[23]

Impact of COVID pandemic

The Lancet commission’s report was published in February 2020, so did not consider the effects of the COVID-19 pandemic that was then just emerging.  We now know that the pandemic has contributed to several further issues affecting children’s health.  While young people were at lower risk, the virus itself has still proved to be a leading cause of mortality among children.  A study last year led by University of Oxford researchers found that the disease ranked eight among causes of death for those aged between 0 and 19 in the US, and was the underlying cause for 2% of deaths.[24]

A 2022 progress report from the WHO makes clear the pandemic has also harmed children’s health in other serious ways, such as destabilizing access to and availability of health services, as well as disrupting education, social protection and economic systems.[25]  With conflict and climate change causing additional disruption, the report says the past two years have seen young people’s vulnerability heighten through factors such as increased rates of child marriage, adolescent depression and anxiety, and violence against women and girls.

One particular concern is falling vaccination rates: Unicef’s executive director says more than a decade of gains in routine immunization have been eroded by the pandemic.[26]  A report from the organization in 2023 said that pressure on healthcare services and stay-at-home orders were among the issues contributing to an increase in children missing routine vaccinations – leading to rates falling to levels not seen since 2008. One in five children are zero-dose (unvaccinated) or under-vaccinated, the report says.  And with confidence in vaccines also falling, there is concern that many children remain vulnerable to preventable diseases such as measles, which one in five children have no protection against.

‘Figure 1’. Source: Unicef

Daunting challenges

Stalling progress on this and other key metrics, combined with ongoing pressure from climate change and global conflict, mean that urgent action is now needed from governments and other stakeholders.

The WHO’s 2022 report on women’s, children’s and adolescents’ health[27] is clear that “progress is too slow”.  It makes several recommendations to help efforts get back on track, including strengthening primary healthcare systems, developing cross-sector collaboration to improve other essential services, and building more resilient food systems.  But while emphasizing the importance of investment, it also notes there is a financing crisis for global health, particularly for low-income countries, which will require unprecedented increases in health spending. This challenge “needs to be addressed as a highest priority”, the WHO report warns.

It’s a sobering assessment. But Unicef’s latest child mortality report does offer some grounds for hope, saying most of the millions of deaths of children and young people that occur each year could be prevented through interventions which are “common, effective and often low-cost”[28].  It highlights how a country’s level of resources does not always correlate with its progress, noting that several low-income countries have managed to outpace the global rate of decline in under-five mortality in recent decades.  Since 2000, this metric has declined by 51% worldwide – but in Malawi and Rwanda, for example, the fall exceeded 75%.  (Factors such as strengthening community health services, devolving responsibility locally, coordinating donors and NGOs and emphasizing data and evidence are believed to have underpinned the latter’s success.[29])

Getting the basics right can go a long way.  But as The Lancet commission makes clear, risks to children’s health increasingly arise from factors that lie outside the traditional remit of healthcare.  So action across a wide range of policy areas will be needed to properly address the situation.  The commission’s recommendations, for example, include a new optional protocol to the UN’s Convention on the Rights of the Child that would require national governments to control which products can be marketed to children[30].  The report also emphasizes the importance of sustainability, stating “the health of children, and their future, is intimately linked to the health of our planet”.  Similarly, Unicef has called on national, regional and local governments to act on issues such as waste and pollution, since “the same issues that are damaging the planet in the long run are also damaging children’s lives today”.[31]

As well as policy, science and innovation are likely to play a part.  One promising new research project, led by Amsterdam University Medical Center, will investigate how climate change is impacting the spread of diarrheal diseases through changes such as flooding or higher temperatures, supporting the development of new interventions.[32]  Digital technology can help support healthcare workers deliver essential services, such as an app co-created by University College London, that provides guidance on newborn care in African countries where there may be limited access to resources.[33]  And exciting new possibilities are arising from cutting-edge developments such as AI.  In Kenya, this is being used to speed up the diagnosis of respiratory diseases, buying valuable time in the fight against diseases like pneumonia, that can kill children within days[34].

Initiatives such as these indicate there is still plenty of hope, with researchers, frontline workers and organizations across the world investing time and resources into improving children’s health.  What is needed now is the leadership to drive these forward and build collective momentum.  Noting that a “major lesson from the pandemic is how much more can be accomplished through partnership compared with acting alone”, the WHO’s progress report[35] calls for a renewed commitment across all stakeholders to meeting strategic goals.

In a similar vein, The Lancet commission calls for a “new global movement for child and adolescent health”, adding that this must incorporate the input of children themselves.  As the commission’s report argued: “Children and young people are full of energy, ideas, and hope… We must find better ways to amplify their voices and skills for the planet’s sustainable and healthy future.”

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[1] https://data.unicef.org/resources/levels-and-trends-in-child-mortality-2024/

[2] https://data.unicef.org/resources/levels-and-trends-in-child-mortality-2024/

[3] https://data.unicef.org/resources/levels-and-trends-in-child-mortality-2024/

[4] https://www.who.int/news-room/fact-sheets/detail/children-new-threats-to-health

[5] https://news.un.org/en/story/2023/01/1132187

[6] https://www.unicef.org/health/childhood-diseases

[7] https://www.who.int/health-topics/child-health#tab=tab_2

[8] https://www.thelancet.com/article/S0140-6736(19)32540-1/fulltext#seccestitle100

[9] https://e360.yale.edu/features/cyclone-freddy-malawi-aftermath

[10] https://www.surrey.ac.uk/news/climate-change-linked-spread-diarrhoeal-illness

[11] https://www.amsterdamumc.org/en/spotlight/tackling-the-effect-of-climate-change-on-diarrheal-diseases.htm

[12] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01797-4/fulltext

[13] https://www.who.int/publications/i/item/WHO-FWC-IHE-17.01

[14] https://www.unicef.org/innocenti/media/1776/file/UNICEF-Report-Card-17-Places-and-Spaces-EN.pdf

[15] https://www.unicef.org/innocenti/media/1776/file/UNICEF-Report-Card-17-Places-and-Spaces-EN.pdf

[16] https://www.who.int/news-room/fact-sheets/detail/electronic-waste-(e-waste)

[17] https://www.unitar.org/about/news-stories/press/global-e-waste-monitor-2024-electronic-waste-rising-five-times-faster-documented-e-waste-recycling

[18] https://iris.who.int/bitstream/handle/10665/341718/9789240023901-eng.pdf?sequence=1

[19] https://www.ilo.org/wcmsp5/groups/public/—ed_dialogue/—sector/documents/publication/wcms_732426.pdf

[20] https://www.ilo.org/wcmsp5/groups/public/@ed_dialogue/@sector/documents/publication/wcms_196105.pdf

[21] https://www.who.int/news/item/15-06-2021-soaring-e-waste-affects-the-health-of-millions-of-children-who-warns

[22] https://www.thelancet.com/article/S0140-6736(19)32540-1/fulltext#seccestitle370

[23] https://www.who.int/news/item/19-02-2020-world-failing-to-provide-children-with-a-healthy-life-and-a-climate-fit-for-their-future-who-unicef-lancet

[24] https://www.ox.ac.uk/news/2023-01-31-covid-19-leading-cause-death-children-and-young-people-us

[25] https://www.who.int/publications/i/item/9789240060104

[26] https://www.unicef.org/media/108161/file/SOWC-2023-full-report-English.pdf

[27] https://www.who.int/publications/i/item/9789240060104

[28] https://data.unicef.org/resources/levels-and-trends-in-child-mortality-2024/

[29] https://www.exemplars.health/topics/under-five-mortality/rwanda

[30] https://www.thelancet.com/article/S0140-6736(19)32540-1/fulltext#seccestitle10

[31] https://www.unicef.org/innocenti/media/1776/file/UNICEF-Report-Card-17-Places-and-Spaces-EN.pdf

[32] https://www.amsterdamumc.org/en/spotlight/tackling-the-effect-of-climate-change-on-diarrheal-diseases.htm

[33] https://www.ucl.ac.uk/made-at-ucl/stories/ucl-co-creates-app-will-improve-newborn-care-globally

[34] https://www.unicef.org/innovation/stories/strengthening-health-systems

[35] https://www.who.int/publications/i/item/9789240060104