McCann, Margaret F.
With this issue, Epidemiology joins with more than 230 journals throughout the world in the Council of Science Editors’ Global Theme Issue on Poverty and Human Development.1 The purpose of this initiative is “to raise awareness, stimulate interest, and stimulate research into poverty and human development.”1 For us as epidemiologists, this theme translates to a focus on poverty and health.
The Millennium Development Goals (MDGs)2 include a litany of high-priority health concerns (Table). Although these Goals cry out for the attention of epidemiologists, they are seldom mentioned in epidemiology circles. The Millennium Declaration and the MDGs were adopted by the member states of the United Nations in 2000; we are now midway between their adoption and the target date of 2015. Results are mixed, but UN officials are confident that the Goals are achievable—if adequate resources are forthcoming.2 Although these necessary resources are primarily financial, they also include a knowledge base to guide the effective deployment of interventions. What are the underlying causes of these health and development concerns? What interventions are most successful? How can indicators of success best be measured? These questions are the domain of epidemiologists.
The 8 MDGs and selected indicators are presented in the Table. Progress has been made in eradicating extreme poverty and hunger (Goal 1), but this progress has not been uniform. Rates continue to be high in both sub-Saharan Africa and Southern Asia (primarily the Indian subcontinent). Jeffrey Sachs3 argues that the poorest countries are trapped below the first rung of the development ladder, unable to gain a foothold. African countries in particular are stuck in this “poverty trap.”
Where poverty is being reduced, income inequality is stark and rising. The poorest 20% of the population in developing countries was responsible for only 5% of national consumption in 1990, and this figure declined to 4% in 2004; the lowest share is for Latin America and the Caribbean, at 3%.4
Rates of primary education (Goal 2) and of disparity between girls’ and boys’ enrollment rate (Goal 3) are improving—again, with dramatic differences among regions. An intervention that illustrates the interrelated nature of the Millennium Goals is providing meals for schoolchildren, which could simultaneously improve their health, their ability to focus on their schoolwork, and their attendance at school.3
Goal 4 calls for a reduction in child mortality. Deaths to children under the age of 5 years (per 1000 live births) have decreased in developing regions from 106 in 1990 to 87 in 2004. Still, these numbers are in sharp contrast to the current rate of 7 per 1000 in developed regions.4 Similarly, the infant mortality rate has declined from 72 to 59 (per 1000 live births) in developing countries, whereas the rate in the developed world is 6. Rates are highest in sub-Saharan Africa. The biggest reductions in child mortality have occurred for children who live in urban areas, whose mothers have some education, and whose families are in the upper income levels.2 There are also unexpected variations among countries; for example, Cuba has a lower infant mortality rate than the United States.5 These comparisons may hold some clues as to which causes of death merit the most attention and which interventions may be most successful.
Another indicator related to Goal 4 is the percent of children who have received at least one dose of measles vaccine. Vaccination efforts since 2000 have dramatically decreased the numbers of measles deaths to children—from 873,000 worldwide in 1999 to 345,000 in 2005.2 Although this decline was sharpest in Africa, vaccination coverage continues to be lowest in sub-Saharan Africa, as well as in Oceania and Southern Asia. Measles vaccination is not only an important indicator in its own right, but serves as a surrogate for access to basic health services. Measles vaccination programs are an opportunity for capacity-building and for providing other interventions, such as mosquito nets and vitamin A supplements.2
Despite the goal of improving maternal health (Goal 5), more than half a million women die each year from complications of pregnancy and childbirth.2 In developing regions, 450 mothers die for every 100,000 live births, compared with 14 in developed regions; the figure for sub-Saharan Africa is 920 and for Southern Asia, 540.4 Causes of death vary considerably among regions, necessitating careful consideration of possible interventions in each locale.2
The proportion of deliveries attended by skilled health care personnel has increased slightly, from just under half to just over half (Table). Women who have completed at least secondary school are twice as likely to have skilled personnel at their deliveries, compared with mothers who have no education.2 Coverage of prenatal care is also improving; most women in all regions are now seen for at least one prenatal visit, although the recommended 4 visits are much less likely.
Prevention of unplanned pregnancy could potentially avert one-fourth of maternal deaths. Contraceptive prevalence is increasing (Table), but remains particularly low in sub-Saharan Africa (21%).2 A recent report from the British Parliament6 states that the Millennium Goals “are difficult or impossible to achieve with the current levels of population growth,” “improved access to family planning is one of the most cost-effective ways of reducing infant and maternal mortality,” and “[t]he ability of women to control their own fertility is absolutely fundamental to women’s empowerment and equality.”
Goal 6 is to combat HIV/AIDS, malaria, and other diseases. The statistics for HIV are grim. Worldwide, 4.3 million people became infected with HIV in 2006; 40 million people are living with HIV; and 2.9 million died of AIDS in 2006.2 HIV prevalence is estimated to be 1.1% for adults (age 15–49) in developing regions and 0.5% in developed regions—and a staggering 5.8% in sub-Saharan Africa.4 Only 28% of persons with HIV in developing regions are receiving antiretroviral treatment.2 Even worse, only 11% of HIV-positive pregnant women receive services to prevent HIV transmission to their infants.2
Malaria intervention efforts have intensified in the last decade; increases are being seen in the percent of children sleeping under insecticide-treated bed nets (Table) and in use of the recommended therapy.2 The prevalence of tuberculosis is also falling (Table).
Ensuring environmental stability (Goal 7) remains well out of reach.2 Emissions of greenhouse gases continue to increase dramatically in both developed and developing regions (Table). The percent of the population using improved sanitation is increasing and the percent of urban residents who live in slums is decreasing, but progress is slow.
A global partnership for development (Goal 8) will require official development assistance, market access, debt relief, and access to affordable essential drugs and new technologies (especially information and communications).2,3 Most critical is the need for developed countries to fulfill their commitments to allocate 0.7% of gross national income to official development assistance, as promised in the Millennium Declaration and subsequent multilateral agreements. Sadly, only 5 countries have so far met this goal (Denmark, Luxembourg, the Netherlands, Norway, and Sweden).2 Official development assistance in 2006 represented only 0.3% of developed countries’ national income and is in fact decreasing: the total in 2006 was $100 billion less than in 2005.
How can epidemiologists play a role in achieving the Millennium Development Goals? Several papers in this issue of Epidemiology provide examples. Fleischer et al8 find depressive symptoms among low-income women in rural Mexico to be associated with such factors as low socioeconomic status (Goal 1: eradicating extreme poverty), low educational attainment (Goal 2: universal primary education), and lack of personal control (Goal 3: empowering women). Cesar Victora9 focuses his commentary on the challenges of assessing progress toward the fourth Goal—reducing child mortality; he asks, “Where are the epidemiologists?”
Marie O’Neill10 and other officers of the International Society for Environmental Epidemiology (ISEE; the journal’s affiliate society) discuss the role of environmental epidemiologists in the study of poverty, environment and health (Goal 7: environmental sustainability). Another paper addressing environmental concerns looks at air pollution, social deprivation, and mortality (Næss et al11). Earlier this year in these pages Colin Soskolne and colleagues in ISEE12 called for expanding the scope of environmental epidemiology to better address the complexities of environmental sustainability. In the same issue, researchers from the World Health Organization concluded that 24% of the global burden of disease was due to environmental health factors, that much of this could be averted by existing cost-effective interventions, and that doing so would address several of the other MDGs.13 Commenting on these 2 papers, Jonathan Samet14 noted that one of the challenges for this ambitious agenda is funding, suggesting that epidemiologists play a role in soliciting funds for this endeavor.
The United Nations report on the Millennium Goals2 notes that political stability and achievement of development goals are interdependent—a point illustrated by Paula Brentlinger and Miguel Hernán15 in their examination of armed conflict and poverty in Central America. Finally, Nancy Krieger16 argues that “epidemiologists cannot ignore poverty” in that poverty and inequity are intertwined with most conditions important to public health.
The MDGs have become the currency of the realm for demographers, economists, and others involved in international development. It’s time for these Goals to become an explicit part of the research agenda for epidemiology, as well.
Figure. Low-tech and...Image Tools
3. Sachs JD. The End of Poverty: Economic Possibilities for Our Time. New York: Penguin Press; 2005.
7. United Nations. Africa Steering Group-Media Advisory
. Accessed September 14, 2007.
8. Fleischer NL, Fernald LC, Hubbard AE. Depressive symptoms in low-income women in rural Mexico. Epidemiology. 2007;18:678–685.
9. Victora CG. Measuring progress toward equitable child survival: Where are the epidemiologists? Epidemiology. 2007;18:669–672.
10. O’Neill MS, McMichael AJ, Schwartz J, et al. Poverty, environment and health: the role of environmental epidemiology and environmental epidemiologists. Epidemiology. 2007;18:664–668.
11. Næss Ø, Piro FN, Nafstad P, et al. Air pollution, social deprivation and mortality: a multilevel cohort study. Epidemiology. 2007;18:686–694.
12. Soskolne CL, Butler CD, IJsselmuiden C, et al. Toward a global agenda for research in environmental epidemiology. Epidemiology. 2007;18:162–166.
13. Prüss-Üstün, Corvalán. How much disease burden can be prevented by environmental interventions? Epidemiology. 2007;18:167–178.
14. Samet JM. Environmental sustainability: a target for environmental epidemiology? Epidemiology. 2007;18:179–180.
15. Brentlinger PE, Hernán MA. Armed conflict and poverty in Central America: the convergence of epidemiology and human rights advocacy. Epidemiology. 2007;18:673–677.
16. Krieger N. Why epidemiologists cannot afford to ignore poverty. Epidemiology. 2007;18:658–663.
© 2007 Lippincott Williams & Wilkins, Inc.