Social Determinants of Health Driving Under-5 Mortality in the US, UAE, and India

Social Determinants of Health Driving Under-5 Mortality in the US, UAE, and India

A comparative case study of SDG indicators and child survival, 2000–2023

Research Team

Abstract 

Under-5 mortality, the probability that a child will die before reaching the age of five, is widely used as a core indicator of a country's overall development and population health. However, global under-5 mortality has declined substantially in recent decades, millions of preventable child deaths still occur each year, concentrated in low- and middle-income countries and linked not only to limited healthcare access but to broader social and environmental conditions in which children are born and raised: poverty, inadequate sanitation, and malnutrition. Under the social determinants of health framework, child mortality reflects structural inequalities and development gaps between countries rather than the performance of any single healthcare system alone.

This project applies that framework to a comparative case study of three countries with contrasting development profiles, the United States, the United Arab Emirates, and India, to examine how three non-health Sustainable Development Goal (SDG) indicators are associated with under-5 mortality between 2000 and 2023. The outcome of interest is SDG 3.2.1 (under-5 mortality rate per 1,000 live births). The three predictors are SDG 1.1.1 (proportion of the population living below the international poverty line), SDG 2.2.2 (prevalence of wasting among children under 5), and SDG 6.2.1 (proportion of the population using safely managed sanitation services).

Data were drawn primarily from the United Nations SDG Global Indicator Database, supplemented by the WHO Global Health Observatory and the World Bank World Development Indicators. By tracing two decades of cross-country variation, the project illustrates how progress on non-health SDGs, such as poverty reduction, nutrition, and sanitation, relates to progress on SDG 3 (Good Health and Well-Being), and supports a multidimensional view of child survival as an outcome of structural development rather than of healthcare systems in isolation.

Research Questions

The main research question guiding this study is how poverty, sanitation access, and child malnutrition are associated with under-5 mortality rates across the United States, the United Arab Emirates, and India between 2000 and 2023.

This question sits at the intersection of four Sustainable Development Goals: SDG 3 (Good Health and Well-Being), SDG 1 (No Poverty), SDG 2 (Zero Hunger), and SDG 6 (Clean Water and Sanitation). The three countries were selected for their contrasting socioeconomic and environmental conditions, which allow broader development patterns to be visible in a small-N comparison: a high-income, structurally complex country (USA), a high-income, rapidly developed country (UAE), and a lower-middle-income country with a much larger population and deeper historical development gaps (India). The 2000–2023 window covers the Millennium Development Goal era and the first eight years of the SDG era, giving enough time for meaningful trends in each indicator to emerge.

Methods

The study used a comparative case study design grounded in the social determinants of health framework. Comparative case study methodology is well-suited to research questions where the goal is to identify common patterns and stark contrasts across a small number of structurally different countries, rather than to estimate effect sizes across a large sample. The approach places the United States, the United Arab Emirates, and India side-by-side on the same set of indicators and asks whether patterns in child mortality track patterns in non-health SDG progress.

Countries and time period: 

The population covered in the analysis includes people living in the United States, the United Arab Emirates, and India, over the years 2000 to 2023. The three countries differ sharply in total population (341 million, 9.77 million, and 1.46 billion, respectively), urbanization (83.1%, 86.8%, 34.5%), and gross domestic product per capita ($85,810, $42,512, and $2,487), but they also differ in the structural conditions poverty, sanitation, and nutrition that the social determinants framework identifies as drivers of child health. This range is a methodological strength: if the same directional relationship between non-health SDG indicators and under-5 mortality appears across countries with very different development profiles, the pattern is more likely to reflect structural development than country-specific idiosyncrasies.

Variables: 

The dependent variable is SDG 3.2.1: Under-5 mortality rate, defined as the probability of dying between birth and exactly 5 years of age, expressed as deaths per 1,000 live births. This indicator is produced from national civil registration systems, censuses, and large household surveys. It is modeled by the UN Inter-agency Group for Child Mortality Estimation to produce comparable annual rates across countries and years.

The three independent variables (predictors) are: (1) SDG 1.1.1: Proportion of the population living below the international poverty line, disaggregated by sex, age, employment status, and urban/rural geography. The international poverty line is operationalized as the World Bank's $2.15/day threshold (2017 PPP). (2) SDG 2.2.2: Prevalence of malnutrition among children under 5 years of age, by type (wasting and overweight). Malnutrition is operationally defined using weight-for-height measurements based on the WHO Child Growth Standards: wasting refers to weight-for-height more than two standard deviations below the median, indicating acute malnutrition and heightened susceptibility to illness and mortality. For this study, wasting is used as the primary measure of child malnutrition because it most directly captures acute nutritional stress linked to under-5 mortality. (3) SDG 6.2.1: Proportion of the population using (a) safely managed sanitation services and (b) a hand-washing facility with soap and water. "Safely managed" sanitation refers to the use of an improved facility that is not shared with other households and where excreta are safely disposed of in situ or transported and treated off-site.

Data sources: 

The primary dataset was the United Nations SDG Global Indicator Database (UN Statistics Division, 2000–2023), which holds annual global and regional SDG indicator values for every member state. This database is the most suitable source for research involving SDGs because it applies consistent operational definitions across all countries and years, enabling accurate cross-country comparison. Indicator metadata (definitions, data-collection notes, and methodological revisions) were retrieved from the accompanying SDG Indicator Metadata repository.

Two supplementary sources were used to cross-check values and fill gaps: the WHO Global Health Observatory (GHO), 2000–2023, drawn on for child health indicators, including diarrhoeal disease context and mortality series and the World Bank World Development Indicators (WDI), 2000–2023, used to verify poverty and sanitation values against World Bank source data, particularly where the UN SDG database had gaps. Both supplementary databases ultimately source their data from the same national civil registration systems and large household surveys that feed the UN SDG database, which supports internal consistency across sources.

Analytical approach: 

Analysis proceeded in three stages. Stage 1 was comparison. The most recent available values for each of the four indicators were compared across the three countries to identify differences in levels of poverty, sanitation access, child wasting, and under-5 mortality. The aim at this stage was to establish whether the countries differ substantially on the predictors, as the comparative design requires variation in the independent variables to be informative. Stage 2 was visualization. Annual values from 2000 to 2023 for each indicator were plotted as time series (line charts with markers, one line per country), enabling visual inspection of both levels and trajectories. Four figures (Figs. 2–5) were produced: under-5 mortality (outcome), poverty, child wasting, and sanitation access. Stage 3 was interpretation. The observed patterns were interpreted against existing empirical and theoretical literature on the social determinants of child health, specifically evidence that poverty, sanitation, and child malnutrition each correlate with higher under-5 mortality. The goal was to assess whether the cross-country patterns seen in this dataset are consistent with the literature's expected directional relationships.

Justification for comparative design: 

The three countries differ by nearly an order of magnitude on several of the predictors of interest, which makes them well-suited to a comparative case study even though they cannot support statistical inference on their own. The USA and the UAE represent high-income contexts with near-universal sanitation access and very low poverty rates; India represents a lower-middle-income country with much larger absolute populations affected by each of the three predictors. If a directional association between non-health SDG indicators and under-5 mortality appears consistently across these very different contexts, this provides tentative comparative evidence, though not causal identification, that the social determinants framework travels across development levels.

Limitations: 

Several limitations should be stated up front. First, consistent data on SDG 2.2.2 (child wasting) for the United Arab Emirates were not publicly available in the UN SDG Global Indicator Database or the supplementary sources, so the malnutrition comparison is limited to India and the United States. Second, the analysis is descriptive and correlational; it does not attempt to establish causal relationships between the predictors and under-5 mortality. Third, comparing only three countries limits generalizability. Finally, the India series for SDG 6.2.1 (sanitation), as drawn from the UN SDG portal for this project, plots at 0% across the full period, a value that is inconsistent with WHO/JMP and World Bank estimates and is almost certainly a data-extraction or plotting artifact. This anomaly is discussed transparently in the Results/Findings and Discussion section and is being re-pulled before final publication.

References

1. United Nations Statistics Division. (2025). SDG Indicators Database. United Nations. https://unstats.un.org/sdgs/dataportal

2. United Nations Statistics Division. (2025). SDG Indicator Metadata Repository. United Nations. https://unstats.un.org/sdgs/metadata/

3. World Bank. (2023). World Development Indicators. The World Bank Group. https://databank.worldbank.org/source/world-development-indicators

4. World Health Organization. (2025, May 6). Social determinants of health (Fact sheet). https://www.who.int/news-room/fact-sheets/detail/social-determinants-of-health

5. World Health Organization. (2023). Global Health Observatory data repository. https://www.who.int/data/gho

6. Merid, M. W., Alem, A. Z., Chilot, D., Belay, D. G., Kibret, A. A., Asratie, M. H., Shibabaw, Y. Y., & Aragaw, F. M. (2023). Impact of access to improved water and sanitation on diarrhea reduction among rural under-five children in low- and middle-income countries: A propensity score matched analysis. Tropical Medicine and Health, 51, 36. https://doi.org/10.1186/s41182-023-00525-9

7. Chao, F., You, D., Pedersen, J., Hu, L., & Alkema, L. (2018). National and regional under-5 mortality rate by economic status for low-income and middle-income countries: A systematic assessment. The Lancet Global Health, 6(5), e535–e547. https://doi.org/10.1016/S2214-109X(18)30059-7

8. Stephenson, L. S., Latham, M. C., & Ottesen, E. A. (2000). Global malnutrition. Parasitology, 121(Suppl. 1), S5–S22. https://doi.org/10.1017/S0031182000006478

9. United Nations Statistics Division. (2025). Metadata for SDG Indicator 3.2.1 — Under-5 mortality rate. https://unstats.un.org/sdgs/metadata/files/Metadata-03-02-01.pdf

10. Martorell, R., & Ho, T. J. (1984). Malnutrition, morbidity, and mortality. Population and Development Review, 10(Suppl.), 4968. https://doi.org/10.2307/2807955

11. U.S. Congress Joint Economic Committee. (2022). The expanded Child Tax Credit dramatically reduced child poverty in 2021. https://www.jec.senate.gov/public/_cache/files/dd209a98-c23b-4b2e-8478-61a55ec2b647/the-expanded-child-tax-credit-dramatically-reduced-child-poverty-in-2021-final-1-.pdf

12. Ministry of Community Development. (2017). National Strategy for Motherhood and Childhood 2017–2021. United Arab Emirates Government. https://u.ae/en/about-the-uae/strategies-initiatives-and-awards/strategies-plans-and-visions/strategies-plans-and-visions-untill-2021/national-strategy-for-motherhood-and-childhood-2017-2021

13. Global Alliance against Hunger and Poverty. (2025). India: National Nutrition Mission (POSHAN Abhiyaan). https://globalallianceagainsthungerandpoverty.org/

NACE Career Readiness Competencies

The National Association of Colleges and Employers (NACE) defines eight career readiness competencies that employers expect of new college graduates. Four of those competencies were developed in a concrete and sustained way through this research project, and each is grounded below in the specific work the project required.

Critical Thinking. The project required evaluating multiple open-access data sources (the UN SDG Global Indicator Database, the WHO Global Health Observatory, and the World Bank World Development Indicators) and deciding which source was authoritative for each indicator, year, and country. When the India sanitation series (SDG 6.2.1) pulled from the UN SDG portal displayed at 0% across the full 2000–2023 period, I had to recognize that this value was inconsistent with independent WHO/JMP and World Bank estimates, diagnose the issue as a data-extraction or plotting artifact rather than a substantive finding, and document the anomaly transparently in the Methods and Results sections rather than present it as a conclusion. Similar judgment calls recurred across the project: interpreting correlational patterns without overclaiming causation, and deciding when a predictor's variation across countries was large enough to be methodologically informative.

Communication. The research had to be rendered in three distinct formats for three distinct audiences: a 3,000-word academic final report for Dr. Mair, a 36"×48" academic poster readable in under 30 seconds per section for the Undergraduate Research Forum poster session, a 10-minute oral presentation for the forum itself, and this accessible Google Site for broader public reference. Each format demanded different word budgets, different density of visual support, and a different tone. Translating the same findings faithfully across those formats, preserving the factual claims while tightening the prose for each audience, required deliberate decisions about what to foreground, what to strip, and how to visually guide a reader through the same underlying argument.

Teamwork. The Youth Well-Being Guided Research program is structured as a five-person group project spanning three countries of assignment (UAE, USA, India). I coordinated with teammates across different disciplinary backgrounds and communication styles, divided analytical responsibility by country, integrated country-specific analyses into a unified comparative framework, and maintained a meeting cadence that kept the project on schedule across a full semester. Producing the group's joint deliverables, the interim report, the final report, and the poster required negotiating authorship, revising one another's drafts, and resolving disagreements about interpretation and visual design.

Technology. Data acquisition relied on the UN SDG Global Indicator Database, the WHO Global Health Observatory, and the World Bank World Development Indicators portals, with indicator-by-indicator download and reconciliation across sources. Time-series figures (Figs. 2–5) were produced in a spreadsheet and matplotlib (Python) environments to match a consistent visual style. The Google Site was built on Miami ORU's template, and the poster will be produced in Google Slides at 48"×36" with accessibility features applied throughout (alt text on figures, color-contrast checks, and readable font sizes). Across all of these tools, version control, file organization, and asset management were handled in a shared cloud workspace.

Research Compliance Protocols

This project uses only publicly available secondary data from the United Nations SDG Global Indicator Database, the WHO Global Health Observatory, and the World Bank World Development Indicators. No primary data were collected from human subjects, no identifiable individual-level data were accessed, and no intervention was conducted. On that basis, the project does not constitute Human Subjects Research under the Common Rule and does not require Miami University IRB approval. Final confirmation of this determination is being obtained from the faculty supervisor before publication.

Acknowledgements

I am grateful to Dr. Christine Mair for her supervision and feedback throughout the Youth Well-Being Guided Research program in Spring 2026, and to Dr. Jennifer Bulanda for her mentorship and guidance in preparing this research for the Undergraduate Research Forum. I thank the Youth Well-Being Guided Research program for the opportunity to conduct comparative SDG research on a meaningful global health outcome, and Miami University's Office of Research for Undergraduates for hosting the 32nd Undergraduate Research Forum. I also thank my Group 3 teammates — Abbey Clovesko, Aleta Ann Alex, Shamma Almarzooqi, and Jannah Elmaghraby, whose collaborative work on the group final report provided the foundation for this individual presentation.

Results and Discussion

Under-5 mortality (SDG 3.2.1):

Under-5 mortality declined in all three countries across the 2000–2023 period (Fig. 2). The magnitude and trajectory of decline, however, differed sharply. India began the period with an under-5 mortality rate of approximately 92 deaths per 1,000 live births in 2000, roughly nine times the UAE (~10) and the USA (~8), and fell the most rapidly of the three, reaching approximately 26 deaths per 1,000 by the end of the series. Despite this steep decline, India's under-5 mortality remained substantially above the UAE's and the USA's in 2023. The UAE and the USA showed parallel, slower declines from already-low baselines, ending the period at approximately 5–6 deaths per 1,000.

The pattern of a common downward direction but very different levels and slopes is the headline finding of the study and sets up the interpretive work for the three predictors. The remainder of this section examines each predictor in turn and asks whether the cross-country pattern in that predictor is consistent with the cross-country pattern in under-5 mortality.

Poverty (SDG 1.1.1):

The first predictor was the proportion of the population living below the international poverty line (Fig. 3). Data availability for the UAE and for some early years in India was limited, but the available observations paint a clear picture. India began the period with a very high poverty rate, approximately 46% of the population living below the international poverty line in the mid-2000s, and showed a strong, roughly monotonic decline across the period, falling to roughly 5% by the early 2020s. The United States and the United Arab Emirates, by contrast, remained at very low levels throughout the period, with the United States fluctuating slightly but always hovering near 1%.

This pattern aligns closely with the under-5 mortality pattern. The country with the highest and most rapidly falling poverty rate (India) also had the highest and most rapidly falling child mortality rate, while the two countries with sustained low poverty rates (USA, UAE) showed sustained low child mortality. The association is consistent with cross-national evidence that under-5 mortality is systematically higher in lower-income settings. Chao and colleagues, for example, documented that children classified as "low-income" face substantially higher under-5 mortality risks than wealthier groups, with exposure to malnutrition, infectious disease, and limited healthcare investment all operating as mechanisms. Poverty, in short, constrains a household's ability to purchase, access, or reach the goods and services that support child survival, food, clean water, and medical care, and this constraint appears in the cross-country comparison.

Child malnutrition (Wasting) (SDG 2.2.2):

The second predictor was the prevalence of wasting among children under 5, operationalized as the proportion of children with weight-for-height more than two standard deviations below the WHO Child Growth Standards median (Fig. 4). India's wasting prevalence ranged approximately 15–20% across the available survey years, with a gradual declining trend over time. The United States' wasting rates remained below 1% throughout the series, consistent with its high-income food environment. As noted in the Methods, consistent UAE data for SDG 2.2.2 were not publicly available, and the UAE series is therefore absent from this comparison.

The India-USA gap here is very large, and the literature provides a direct mechanistic link between this gap and the under-5 mortality gap. Stephenson and colleagues observed that stunting and wasting are concentrated in many developing regions and have a direct, strong correlation with higher under-five mortality. Martorell and Ho documented that mortality risk rises not only among severely malnourished children but also among those who are moderately undernourished; malnutrition weakens immune defenses and contributes to a reinforcing cycle in which infection and poor nutrition worsen each other. In practice, malnutrition raises the incidence and severity of the two largest proximate causes of under-5 death globally, diarrhoeal disease and respiratory infection, both of which are themselves sensitive to sanitation and healthcare access. The higher proportion of wasted children in India is therefore a plausible partial explanation for its higher under-5 mortality rate compared to the United States, and this supports the broader framing that child survival depends on basic living conditions, food security, household resources, and access to essential services as much as on the healthcare system.

Sanitation access (SDG 6.2.1):

The third predictor was the proportion of the population using safely managed sanitation services (Fig. 5). The USA and the UAE maintained near-universal (~97–100%) safely managed sanitation coverage across the entire 2000–2023 period. The India series, as pulled from the UN SDG portal for this analysis, plots at 0% across the full period, which is inconsistent with WHO/JMP and World Bank estimates that place India's safely managed sanitation coverage in the tens of percent and rising. This is almost certainly a data-extraction or plotting error rather than a substantive finding, and the series is being re-pulled and cross-checked against the World Bank WDI indicator SH.STA.SMSS.ZS before final publication.

Despite the data issue in Fig. 5, the substantive literature on sanitation and child health is strong enough to frame what the corrected series is expected to show. Diarrhoeal disease is one of the leading direct causes of under-5 mortality globally, especially in settings with limited access to safe water and sanitation. Merid and colleagues' propensity-score analysis in low- and middle-income countries found that children in households with improved water and sanitation experienced significantly fewer diarrhoeal episodes than those with unimproved services, and that combined improvements to both water and sanitation produced larger reductions in diarrhoeal disease than either intervention alone. The existing Fig. 5 pattern for the USA and the UAE  near-universal sanitation coverage is consistent with the very low diarrhoeal-disease burden and low under-5 mortality observed in those countries; the anticipated corrected India series (a substantial but incomplete coverage that has risen over time) would be consistent with India's intermediate and improving mortality picture.

Integrating the three predictors:

Taken together, the three predictors tell a coherent story. The country with consistently high under-5 mortality (India) also had consistently high poverty, high child wasting, and incomplete sanitation coverage. The two countries with low under-5 mortality (USA, UAE) also had low poverty and near-universal sanitation access (and, for the USA, low wasting). The country that made the greatest progress on child mortality (India) also made the greatest progress on poverty. These are not independent storylines: poverty constrains access to food, water, and healthcare, which in turn shapes malnutrition and exposure to diarrhoeal and respiratory infection. The patterns are consistent with the social determinants of health framework's central claim that health outcomes are produced by the conditions in which people live, not only by the healthcare system they interact with.

This finding has two practical implications for the subsequent policy discussion. First, child survival in any of these three countries is partly a story about non-health policy, poverty programs, nutrition programs, and sanitation infrastructure. Policies that target only the healthcare system will leave substantial gains on the table. Second, the countries that have made the largest gains on under-5 mortality have made those gains while simultaneously making gains on the upstream determinants, which suggests that integrated, multi-sectoral strategies outperform narrowly health-sector strategies.