摘要：Today, many of the 10 million childhood deaths each year are caused by diseases of poverty—diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed. IN A RECENT SERIES OF PAPERS on child survival in the Lancet , 1– 4 neonatal causes, diarrhea, and pneumonia were quoted as major causes of the 10 million childhood deaths that occur each year. 1 In spite of evidence that interventions reduce mortality, the coverage of such interventions is still too low, 2 and the delivery of services is not sufficient. 3 In addition, poor children are disadvantaged in terms of exposure to and resistance to disease, coverage levels for preventive interventions, and use of health care when they are sick. 4 A major issue for many governments is how to reduce mortality and ensure that interventions to reduce mortality also reach poor children. Diseases such as diarrhea and pneumonia are diseases of poverty, 1 and they were major causes of childhood death in many European countries a century ago. Specific analyses of the historical decline of child mortality in these countries may shed light on the potential overall and equity impact of certain interventions to reduce child mortality, such as improvement of water and sanitation. The historical time period and cause-specific patterns of child mortality may also be informative. Previous studies of infant mortality in Stockholm from 1878 to 1925 5 showed a transition over time in the age structure and cause-specific composition of mortality analogous to the country typology described 1 ; diarrhea and pneumonia initially were the main causes, and as they declined, neonatal causes subsequently increased in relative importance. Infant (< 1 year) mortality rates exceeded 200 per 1000 in Stockholm until 1900 and declined to 50 per 1000 by 1925. Most of the decline, which occurred in the postnatal (1–11 month) period, was driven by a decline in diarrhea mortality. Other important causes of death included congenital conditions; tuberculosis; meningitis; undernutrition; and other diseases associated with poverty, crowding, and adverse living conditions, which were a reality for the majority of the rapidly growing urban population in Stockholm. 5 There were probably many causes of the decline in diarrhea mortality; improvements in the provision of water and sanitation, changes in hygienic perception and behavior, and general socioeconomic improvements, including improved nutritional status, are all thought to have been contributing factors. 6 Obviously, the mortality decline occurred in the absence of other specific interventions such as immunization and effective curative interventions. Against this background, we analyze the impact of improvements of water and sanitation in Stockholm from 1878 to 1925 on overall mortality and diarrhea mortality, both in general and by socioeconomic group.
