Moving beyond survival to include child development

MARKO KERAC: So 2003, for me, was a big year. It was the year when I first went out to work as a junior paediatrician at Queen’s Hospital, College of Medicine, Malawi. Many things from my practise in the UK were familiar, other things strikingly different. One of those was a handover meeting, when the intern, who had been on call the previous night, would report all the interesting, challenging, complex cases that had come in. And one of the things that was strikingly different was the report of deaths. Whereas, in the UK, I had only ever witnessed a handful of deaths in my clinical peds practise. In Malawi to have one, two, three or more deaths was sadly not at all unusual.

The strange day was a day when there were no deaths reported. And so, obviously, our focus was on reducing that child mortality. 2003 was also a key year, in that the seminal Lancet Child Survival Series was launched. That reported 10.8 million child deaths per year worldwide. And strikingly, 60% of those were preventable with existing, affordable, available interventions, if only they could be scaled up to reach those in need. And they focus particularly on the treatment and prevention of infectious disease, pneumonia, diarrhoea, malaria, HIV/AIDS. Since 2003, great progress has been made. Global child mortality has almost halved. Malawi’s has more than halved. It’s one the great success stories of the Millennium Development Goals. But there is still work to be done.

Child death is still higher than they could be, higher than they should be. There is progress to be made. But there’s also an important new agenda come up. It’s no longer enough for children just to survive, it’s also important that we give them the chance to thrive, to fulfil their full potential in life. Malnutrition is important for both the survive and thrive agendas. In all its forms, it underlies some 45% of global child deaths at present. But it also has big implications for childrens’ ability to thrive, to fulfil that full potential in life. And we’ll discuss stunting, one of the commonest forms of under-nutrition, in the next session.

But for now, just a few examples of why malnutrition really matters, and why we need to think and act beyond child survival alone. So the first is a study by Sally Grantham-McGregor, et al. Again, published in The Lancet in 2007. And they estimated that over 200 million children worldwide don’t achieve their full developmental potential. So this has implications for individuals, families, whole societies. And as they said, these disadvantaged children are likely to do poorly in school, and subsequently, have low incomes, high fertility, and provide poor care for their children, thus contributing to the intergenerational transmission of poverty.

Disability is another important issue. Malnutrition can cause specific types of disability, and in turn, disability can underlie or exacerbate malnutrition. And it’s important we see the links between the two and take it as an opportunity for synergy, for programmes to work together to positively impact on better treatment of both conditions. And the third example is from work that I’ve been doing with colleagues in the Malawi. And we’ve been following up on a cohort of children who had severe, acute malnutrition in 2006-7 And we’ve been following them up at one year post discharge, and most recently, at seven years post discharge. And what’s striking, is the high mortality.

Again, out of a cohort of 1,000 children initially, at one year post discharge, only 460 were still alive. Most recently, 350 still alive, so huge child mortality. But it’s also important to note that these are the healthiest survivors. These are the fittest survivors. That’s why they’re still alive. But they are far from fit and healthy. Compared to their siblings, and compared to community controls, they are significantly more stunted. And ironically, this has implications for later-in-life risk of obesity. So they’ve gone from being undernourished to now being at high risk of obesity and all the health problems that come with that. There is now growing evidence of late life consequences of early life malnutrition adversity.

So this is the Barker, or developmental origin of adult disease, DOAD hypothesis. And this states that those early life exposures really matter for later-life adult health. And this all matters because there is now a growing tide of chronic disease in lower and middle income countries, and this threatens to overwhelm already fragile and poorly resourced health systems. But we can turn this problem into an opportunity. By strengthening child survival initiatives we cannot only have benefits in the short term, but we can have huge benefits in the long term, helping children thrive, helping them achieve their full physical, cognitive, social potential in adult life. And it’s an opportunity for a win-win scenario –better child survival, but also helping them thrive.