Young people: not as healthy as they seem.

Over the past 25 years, there have been major shifts in causes of mortality and morbidity among young people (aged 10–24 years). HIV/AIDS was essentially unknown 25 years ago, and other infectious diseases, such as pulmonary infections, were leading causes of death in this age-group. Suicide was less common than it is today, and deaths from motor vehicles were much less frequent in many countries of the world than they are now. Additionally, in 1985, more young women married at an earlier age than they do today, fewer young people went to school, and increased numbers lived in rural areas. All of these trends have aff ected mortality and morbidity in young people. Other patterns of change, specifi cally present and anticipated demographic changes, are worth considering when we explore adolescent mortality. Today, almost a third of the world’s population is aged 10–24 years, and in many developing nations 30% or more of the population fall into this age-group (compared with about 13% in Europe, Japan, the USA, and Canada). Just below 90% of the world’s young people live in developing countries, and during the next 20 years that proportion will increase. By 2025, the 140 million young people in Europe in 2006 will decline to 111 million, whereas in Africa the proportion of young people will rise from a 2006 fi gure of 305 million to 424 million (an increase greater than the entire population of young people in Europe). Other global patterns aff ect the health of young people, such as transnational migration, rural-to-urban migration, increased migration of young women, delay in age of marriage, and rises in rates of education, especially of girls. All these changes aff ect behaviours (eg, premarital intercourse) that predispose to other consequences, such as sexually transmitted infections (including HIV) and out-of-wedlock pregnancy and abortion—all of which are refl ected in mortality data. Although adolescence is often referred to as the healthiest stage of life, the report by George Patton and co-workers in The Lancet today makes clear that young people are at substantial risk of mortality. They have shown that risk of mortality rises with age, that two-thirds of deaths in this age-group take place in two regions of the world, and that the causes of adolescent death vary greatly by geographical region and national and personal resources. What distinguishes the causes of death of young people is that most deaths have behavioural causes exacerbated by national policy or failures of healthservice delivery systems, or both. In industrialised countries, young men are two to four times more likely to die than are young women, and homicide, suicide, and injury account for between 50% and 80% of adolescent mortality. However, because of deaths from HIV/AIDS and maternal mortality, the same gender disparity in mortality patterns is not seen in Africa, south Asia, and southeast Asia where most of the world’s young people live and where most juvenile mortality clusters. WHO estimates that more than 250 000 pregnancyrelated deaths happen worldwide. Early childhood marriage contributes greatly to this mortality fi gure as does the practice of female genital cutting, which signifi cantly adds to morbidity. Where abortion is illegal and clandestine, abortion-related mortality is as high as 60 per 100 000 women, compared with 0·6 and 1·0 per 100 000 women, respectively, for the USA and Cuba, where it is legal. Worldwide, more than a quarter of maternal mortality stems from national abortion policies, and when those policies are reversed maternal mortality plummets. We need only to look at South Africa’s greater than 90% reduction in maternal mortality that took place when abortion became legal to see the consequences of restrictive abortion policies. Another diff erence in mortality patterns worldwide relates to HIV and its transmission. In Europe and North America transmission is still mainly between men who have sex with men, and two-thirds of those who are infected are men. In much of southeast Asia, intravenous drug use is the predominate mode of transmission for HIV infection, and as a result a sex parity is observed. In See Articles page 881