Intended for healthcare professionals


Reduction of childhood mortality through millennium development goal 4

BMJ 2011; 342 doi: (Published 10 February 2011) Cite this as: BMJ 2011;342:d357
  1. Adnan A Hyder, director1,
  2. Jeffrey Lunnen, intern 1
  1. 1Johns Hopkins International Injury Research Unit, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
  1. ahyder{at}

Will not be maximised unless injury prevention is integrated into the overall plan

Millennium development goal 4 aims to reduce mortality in children under 5 years by two thirds between 1990 and 2015. Unfortunately, as of 2010, among the 67 countries with high child mortality (≥40 deaths/1000 live births), only 10 are on track to meet this target.1 At the millennium development goal summit in September 2010, the general assembly of the United Nations adopted an outcome document that expressed “deep concerns that [progress] falls short of what is needed.”2 The lack of focus on prevention of childhood injury in many countries is exacerbating the failure to meet the target.

About 830 000 children under 18 years die each year as a result of unintentional injuries, including road traffic injuries, poisoning, falls, burns, and drowning. In addition, tens of millions of children require acute hospital care or long term rehabilitation for non-fatal injuries. Globally, injuries are the leading cause of death for children aged 10-19 years, and road traffic injuries and drowning account for nearly half of all unintentional injuries to children.3

More than 260 000 children die as a result of road traffic injuries each year, and up to 10 million more are non-fatally injured.3 Both sexes are affected, although twice as many boys as girls die from road traffic injuries.4 The global cost of road traffic injuries has been estimated at $500bn (£320bn; €385bn) annually.3 More than 450 children drown each day worldwide, and thousands have serious lifelong disabilities, including brain damage, as a result of non-fatal drowning events.3 In Bangladesh, for example, 20-29% of deaths in the 1-4 year age group are caused by drowning.5 Burns kill 96 000 children annually and are more common in girls because they are more likely be exposed to fire at home, a result of socially defined gender roles. Each year, another 45 000 and 47 000 children die from poisoning and falls, respectively, around the world, and the toll of these injuries on the health system is even higher because of the millions of non-fatal events.3

Although 40% of all deaths in children in high income countries are caused by injuries, 95% of childhood deaths from injury occur in low and middle income countries.3 Rates of death from injury in children are more than four times higher in low and middle income countries than in high income countries.6 This inequity means that regions like sub-Saharan Africa and South Asia, which are among the most populous and poorest regions in the world, have some of the highest incidence rates and fatality rates for childhood injury.7

Children are highly susceptible to injuries, which are preventable causes of death and disability.1 Yet low and middle income countries generally have few data on childhood injuries, lack national policies on the prevention of such injuries, and have very few funded programmes or research in this area.3 This oversight not only increases loss of healthy life, with consequent social and economic effects, but may also have serious implications for the achievement of millennium development goals related to child health.

Given the size of the problem, the relative lack of global attention to childhood injuries in terms of public policies and resource investment is surprising.8 Although the World Health Organization and United Nations Children’s Fund (Unicef) released a world report at the end of 2008 on childhood injuries, they seem to have little budgetary support to act on it. The almost 1000 attendees at the September 2010 World Conference on Injury Prevention and Safety Promotion ( in London also highlighted insufficient global interest and called on governments to be proactive in confronting this burden on the world’s children.

Childhood injuries are not simply “accidents”—many of them can be prevented or the severity of their effects reduced.8 Experience in developed nations has shown that interventions for preventing injury can be effective; high income countries have reduced deaths from childhood injury by 30-50% over the past 30 years by implementing multi-sectoral approaches to the prevention of childhood injury.3 5 Effective preventive methods include implementing and enforcing safety legislation and standards; promoting home and transport safety; modifying products and the environment where children live and play; and improving care and rehabilitation of injured children.6

Specific injury prevention and control interventions are available. For example, approaches to reducing childhood road traffic injuries include introducing laws on minimum drinking age; implementing lower blood alcohol limits for teenage drivers; making motorcycle helmets, seat belts, and child restraints mandatory; reducing speed around schools; and introducing graduated driver licensing (whereby a full licence is not given until a specified number of hours have been driven).3 Interventions to prevent drowning include removing or covering water hazards; fencing swimming pools; providing personal flotation devices; and ensuring immediate resuscitation.3 These interventions are effective and cost effective, giving high returns for investments (table).9 10

Benefits of investments for injury prevention and control interventions3 9 10

View this table:

Despite this knowledge, the lack of implementation—especially in low and middle income countries—is staggering. Governments, civil society, and the private sector must create safer physical and social environments for children and safer products, such as toys and musical instruments. A comprehensive approach to the prevention of childhood injury should include developing national policies to promote action, improving legislation to ensure safety, investing in evidence based programmes, and supporting relevant research to adapt and modify interventions to local contexts. Health and medical professionals, especially in low and middle income countries, need to accept that the acute transfer of energy (instead of a biological agent) through human bodies causes injuries; the use of public health sciences helps identify the causes of injuries; and solutions for injury prevention and control are multi-sectoral and come from within and outside of the health sector.6


Cite this as: BMJ 2011;342:d357


  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


View Abstract