The Grand Divergence in Global Child Health: Confronting Data Requirements in Areas of Conflict and Chronic Political Instability.

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 countingandcausal attributionofmorbidityandmortalityprovide 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 themoral basis of global health and its commitment to the rightsandsocietal claimsof thosewhose health and well-being have for too long gone unnoticed. At a global level, available data demonstrate that dramatic reductions inchildmortalityhaveoccurred inmany lowand middle-income countries. Moreover, long-standing disparities in survival between materially wealthy and poorer regions of theworld are dissipating. If sustained, this historic recordof reducedmortality inequalitycoulddrivea“grandconvergence” in life expectancy during the next 2 decades.1 This prospect has been used constructively to advocate for a continuedglobal commitment to economicdevelopment 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 stagnantor, in somearenas,worsening childhealthoutcomes. Indeed, these countries could bedescribed as contributingtoa“granddivergence” in lifeexpectancies, inwhichtheir health indicators fall increasingly behind those of other lowandmiddle-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 fieldof global health andprovides troublingevidenceof thediverging trends inchildhealth andwell-being.3What is nowevident fromeven a cursory examinationofpresentedchildmortality trends is that the countries making the least progress in child survival and wellbeing, particularly since 2000, are those most likely to be plaguedbychronic civil conflict, political instability, andweak governance.NigeriaandtheDemocraticRepublicof theCongo, which together account formore thana thirdof all childdeaths in sub-SaharanAfrica, experienced annual childmortality declinesof 2.2%and 1.8%, respectively (eTable9 in their Supplement). It is useful to note that during this same period among themost 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 childmortality andmorbidity 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. Of special note is the estimation of the specific causes of mortality and morbidity patterns in the countries under study. Many readers who care about global child health but who are not directly engaged in the generation of global child health data may not fully recognize just howdifficult it is to create the numbers presented in this article. Most high-income areas of the world possess well-functioning vital registration systems that enumerate births and deaths with general accuracy and regularly conductnational health surveys that include informationonchild illness and injury.However,many areas of theworld, particularly those experiencing the highest burden of childhood illness and death, have no such systems. The figures presented in the GBD 2013 study article for these countries therefore do not represent population-based tallies of actual recorded events. Rather, they represent estimates generatedby sophisticatedmodelsbasedondemographicpatterns fromareaswith relatively good data that are then applied to whatever child mortality and morbidity data could be gleaned from published reports or other data sources for a particular country or region. The tabulations presented in the GBD 2013 reports therefore represent a remarkable combinationof statistical expertise and data-mining grunt work. Indeed, the collaborative infrastructure of the GBD initiative has proven to be one of the most important analytic advances in global health in recent decades. It is useful to briefly review themajor data sources available for theGBD2013 study and other estimates of childmorbidity andmortality. Globally, only about half of all births are registered and fewer than half of all deaths are actually capturedbywell-functioningcivil registrationandvital statistics.4 As inmosthigh-mortality, sub-Saharan countries,Nigeria, the Democratic Republic of the Congo, and Angola record fewer than 10% of deaths in formal systems and data on stillbirths are essentially missing. The GBD 2013 initiative must therefore rely on a series of alternative sources of data for countries of greatest concern. Among themost important of these Related article page 267 Opinion