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.

As in European countries a century ago, diarrhea is a major cause of child mortality in poor countries today. In Stockholm at the turn of the 19th century, political commitment, infrastructural investments in water and sanitation, and enforcement of sanitary improvements by a strong implementing organization helped eliminate diarrhea as a principal cause of death among children. These interventions also had an equitable impact on social class differences in diarrhea mortality, but not on overall mortality; overall mortality declined, but class differences remained. General infrastructural improvement and health education coupled with targeted interventions to vulnerable children may be successful in improving child health and reducing social differentials in mortality. Specific health care interventions may need to be complemented by infrastructural investments to improve water and sanitation if diarrhea mortality is to be further reduced in poor countries today.