LAUSR

In March 2015, an Archives editorial featured a Lancet paper describing neonatal, infant and child mortality trends, comparing UK data to other European countries and Canada, but not the USA (doi: 10.1136/archdischild-2014–3 07 678). The UK was improving more slowly than the comparator countries. Now American authors have done something similar (Khan S et al doi:10.1001/jamapediatrics.2018.3317). Using the US National Centre for Health Statistics database, and comparing to equivalent data from England/Wales (E&W) and Canada, they found that the US is actually doing much worse than the UK. They looked at annual mortality rates for all individuals up to age 24, from 1999 to 2015, throughout the US. As seen in other countries, there was a striking decline in overall mortality rates for most age groups over the 16 year period, except for young adults aged 20–24 where there was a decline until 2012 and then a slight increase. In all age groups and in every year, US mortality rates were substantially higher than either Canada or E&W, and there was no evidence of the gap narrowing: on the contrary, for adolescents it was getting wider. For example, for infant mortality, US rates fell from about 750 per 100 000 in 1999 to 590 in 2015, while in E&W it fell from about 590 to 390 over the same period. US adolescent mortality (age 15–19) fell from 68 per 100 000 to 48, and in E&W from 40 to 25. Generally, Canada did slightly worse than E&W. The main focus of this paper is on differences by race/ethnicity in the US. The differences were massive and frankly quite shocking. Mortality in black infants was more than twice that seen in whites: overall 1130 vs 500 per 100 000. There was some narrowing of these ethnic differences over the 16 year period for infants and children but less so for adolescents, and for young adults it got wider. They were able to look at causes: the reasons for improvements in infants and children are clear: fewer deaths from SIDS, infections, malignancies and injuries. The increases in young adults were mainly due to suicides and unintentional drug poisonings. The persistently higher neonatal mortality in black babies is largely due to prematurity and low birth weight, linked to poor maternal health and inadequate antenatal care. The authors comment that the US is a wealthier country with much greater total spending on healthcare than the comparator countries with lower mortality rates. But we in the UK, Canada and Europe should not be complacent: although the 2014 Lancet paper did not address ethnicity, even here there remain substantially higher mortality rates for deprived communities and certain ethnic groups.