Drowning prevention: turning the tide on a leading killer

Summary

Drowning is a leading killer, particularly of children and young adults, yet has been greatly neglected. Despite accounting for a higher number of deaths than many other substantial public health issues, drowning has not benefitted from the targeted attention it requires, which is particularly tragic because low cost and effective drowning prevention interventions exist. Therefore, the recent UN General Assembly's adoption of a resolution on global drowning prevention is a historic first, and offers an exciting opportunity by providing a comprehensive framework and a practical roadmap that a range of actors and sectors, including governments, can follow to address the challenge of drowning prevention.

A newly recognised public health issue

In the past decade, drowning has claimed more than 2·5 million lives.¹ Many of those lives lost were of children who, during a momentary lapse in supervision, slid unnoticed under the water's surface. Some of the lives lost were of fisherfolk, typically because livelihood needs drove their decision making in the context of unsafe watercraft and inadequate systems to provide weather warnings. Some lives were lost during mass casualty events, such as an overcrowded passenger ferry capsizing far from shore, or an open dinghy taking several extended families to a neighbouring island and failing to arrive. Some lives were lost during increasingly frequent flood-related disasters, in which entire coastal communities have been devastated by typhoons, cyclones, or hurricanes.

The first WHO Global Report on Drowning in 2014² provided data using the 2012 Global Health Estimates and identified several striking facts: drowning was among the ten leading causes of death for people aged 1–24 years in every region of the world; half of all drowning deaths occurred in people younger than 25 years; drowning deaths numbered almost two-thirds of deaths caused by protein–energy malnutrition; and more than 90% of deaths occurred in low-income and middle-income countries (LMICs).² According to WHO's most recent Global Health Estimates,¹ in 2019 a total of 236 000 people drowned, meaning drowning deaths now exceed deaths from either protein–energy malnutrition or maternal conditions.

Crucially, drowning disproportionately affects the poor and marginalised, who are the populations with the least resources to adapt to the risks around them, with rates in LMICs over three times higher than in high-income countries (HICs).² Among WHO regions, drowning death rates are highest in the Western Pacific region, followed by the Africa region.¹ Collectively, the Western Pacific and South-East Asia regions account for more than 60% of global drowning mortality.¹ National surveys have shown that drowning can occur anywhere with water, such as containers, wells, irrigation canals, and natural water bodies.^{3, 4} A large survey in Bangladesh⁴ found that 80% of drowning in children younger than 5 years occurred within 20 m of the family home, whereas older children and adults tended to drown farther away and most typically while collecting water, working, or travelling on water. In a survey of lakeside communities in Uganda,⁵ young adult men in boats accounted for more than 80% of drowning deaths, and a survey of such communities in Tanzania⁶ found that adult fishermen were the most likely group to drown and that drowning mortality exceeded each of the national death rates for malaria, tuberculosis, and HIV.

Drowning is also prevalent in HICs. It is the second leading cause of death in children aged 1–4 years in Australia, France, New Zealand, Switzerland, and the USA, and the sixth leading cause of death for children and young adults aged 1–24 years for all HICs combined.¹ Risk factors include absence of supervision and exposure to water hazards such as swimming pools in young children, and the absence of swimming skills in school-age children.⁷

Flood-related disasters can also lead to drowning. Both the number of people exposed to flood hazards and the severity of flood-related disasters are increasing, and are projected to grow further, as a result of climate change.⁸ Floods are the most common type of natural disaster and the leading cause of mortality in disasters, and drowning is the leading cause of death during floods.⁹

Climate change is having many effects on human health and the relationship between climate change and drowning is not limited to flooding. For example, of the world's 60 million people engaged in fisheries or aquaculture, the majority are small-scale artisanal fisherfolk of whom 85% are located in Asia and a further 9% in Africa.¹⁰ Ocean warming from climate change is affecting the growth, reproduction, and survival of fish stocks, thereby diminishing fishery productivity in many regions.¹¹ This is pressuring fisherfolk to fish further afield, meaning longer times on the water in vessels that might not be suited to the conditions, an identified risk factor for drowning for one of the most hazardous of occupations.¹²

Several factors create bias towards the under-reporting of drownings. Data-categorisation methods exclude deaths by intentional drowning or related to floods or transport by water. Also, the inherent lethality of a drowning episode means that many victims never reach a medical facility at which the death could be recorded.² Data from HICs suggest that such data categorisation methods lead to drowning rates being under-represented by up to 50%,¹³ and survey data from several LMICs suggest that rates are 4 or 5 times higher than WHO estimates.¹⁴

The emerging evidence for effective prevention

Research on drowning is increasing. A recent study found that such publications increased by a factor of 103 between 1995 and 2020, with over 40% of these being published since 2014.¹⁵ Governments, the UN, donors (ie, philanthropic organisations and charities), and researchers have started to explore drowning and its prevention in LMICs. These efforts are informing an increasingly nuanced understanding of drowning and the implementation of drowning prevention in such countries.

WHO provides guidance on implementing the following interventions and strategies to prevent drowning: provision of day care for preschool children (typically younger than 6 years), barriers to control access to water, provision of basic swimming skills and water safety training to school-age children (typically aged 6 years and older), training bystanders in safe rescue and resuscitation methods, building flood resilience measures and managing flood risks, and setting and enforcing regulations for safe shipping, boating, and ferrying.¹⁶

A compelling aspect of several interventions to prevent drowning is their potential to provide synergistic benefits. For example, the provision of day care for preschool children was initially trialled as a prevention initiative after drownings in this age group were noted to correlate with lapses in supervision, typically because both parents had to be engaged elsewhere.^{17, 18} Day care has been shown to provide a relative risk reduction for drowning of 82%, and in terms of cost-effectiveness to compare favourably with other child-survival strategies such as oral rehydration therapy.^{2, 18, 19} Furthermore, the provision of day care has other desirable effects, such as improving outcomes such as increases in cognitive ability and academic achievement and decreases in the need for special education or retention in grade.^{20, 21, 22}

Basic swimming and water safety skills have been shown to be effective and even more highly cost-effective than day care at preventing drowning mortality.¹⁸ Synergistic benefits include increased physical activity and increased safety knowledge.²³ Also, such programmes are well suited to being integrated within educational curricula, thereby enabling the leverage of education sector resources to help prevent drowning.

Integration into, and the leveraging of, a range of sectors is an important aspect of supporting national programming. For example, the Vietnamese Government has adopted a national action plan that will use resources in the educational and other sectors to provide basic swimming and water safety knowledge to school-age children throughout the country. The plan aims to ensure that by 2030, 60% of children of primary and lower secondary school age (ie, 6–16 years) can swim, and that 70% have water safety skills. In 2015, the Bangladesh Government passed legislation requiring swimming lessons to be taught in schools, and Bangladesh is close to adopting a national drowning-prevention plan.

Thailand and the Philippines have implemented national drowning-prevention programmes that involve a range of sectors and rely on interventions recommended by WHO. Similarly, Papua New Guinea, where transport between islands is a major driver of drowning, has focused on improving boating safety, particularly through requiring improved, more buoyant dinghies and equipping these with appropriate flotation devices for users. The involvement of multiple sectors in drowning prevention reflects the fact that a wide range of factors and hazards shape drowning risk, and solutions and potential solutions rest with many sectors. From fisheries to education to rural development, and from maritime safety to disaster-risk management, drowning has no single constituency. Yet multisectoral approaches are clearly practicable for national governments, and public-health actors are gaining a better understanding of the factors driving effectiveness of multisectoral alliances.²⁴

A historic framework for moving forward

Despite the human and financial costs and the potential for action, drowning has largely been absent from the international political agenda. Therefore, the adoption of the first ever resolution on global drowning prevention by the UN General Assembly on April 28, 2021, is a milestone. The resolution's original sponsors, Bangladesh and Ireland, were joined by 79 other member states at the time of adoption. Among other calls to action, the resolution invites WHO to coordinate drowning- prevention efforts within the UN system, proclaims July 25 as World Drowning Prevention Day, and calls upon WHO to facilitate observance of this day.

The resolution recognises the multisectoral nature of drowning prevention and draws the attention of member states to the connections between drowning and the UN 2030 Agenda for Sustainable Development. Progress in achieving some UN Sustainable Development Goals (SDGs; such as those related to child survival, resilience to disasters, or safe water, sanitation, and working environments) would be expected to contribute directly to drowning prevention.²⁵ This means that solutions for preventing drowning are likely to exist within societal and environmental SDGs, but will require partnership, research, and action across a range of sectors and actors working within them, including stakeholders not yet working in drowning prevention. Similarly, deeper engagement with drowning prevention can accelerate progress towards achieving some SDG targets. An example would be the SDG target to eliminate preventable deaths in children younger than 5 years. In fact, because peak drowning rates occur in children aged 1–4 years,² a compelling case can be made that not addressing drowning prevention could undermine the investments made by the global community to ensure child survival.

Given the increase in flood-related disasters and related drownings,^{8, 9} the UN resolution also draws attention to connections with action on global climate change and the Sendai Framework for Disaster Risk Reduction 2015–2030.²⁶ Implementing the measures necessary to reduce risk of drowning and other societal effects during flood disasters is an urgent multisectoral challenge, but one that will ultimately yield benefits in terms of increased resilience of communities to floods.

The resolution provides a thoughtful, comprehensive framework for targeted and coordinated action on drowning prevention across all the relevant sectors (panel). This historic resolution can therefore serve as both a springboard and a roadmap to catalyse the action necessary to be taken across the sectors that can mitigate drowning risk.

Panel. Priority elements of the UN resolution on global drowning prevention.

• •Appoint a national focal point for drowning prevention
• •Develop a national drowning prevention plan
• •Develop drowning-prevention programming in line with WHO-recommended interventions
• •Ensure the enactment and active enforcement of water-safety laws across all relevant sectors
• •Include drowning within civil registration and vital statistics registers
• •Promote drowning-prevention public awareness and behaviour-change campaigns
• •Encourage the integration of drowning prevention within existing disaster-risk reduction programmes
• •Support international cooperation by sharing lessons learned
• •Promote research and development of innovative drowning-prevention tools and technology
• •Consider the introduction of water safety, swimming, and first-aid lessons as part of school curricula

Although this resolution is an important milestone for drowning prevention, there are still several challenges and keys to success that are worth discussing. For example, the call for each member state to appoint a national focal point affirms the usefulness of having a single ministry, institution, or other entity that is tasked with overall coordination of drowning prevention. But this requirement can pose challenges for decision making and affect the momentum afforded to the issue; ultimately, the success or failure of the issue can hinge upon how astutely the focal point was selected.

The UN resolution also calls for a high degree of coordination and integration. The emphasis is on coordination across the government of a member state; however, in both LMICs and HICs, development of evidence-based programming for drowning prevention has benefited from the engagement of civil society actors and academia in addition. Successful whole-of-society approaches can help to ensure that important frameworks (eg, national drowning-prevention plans) are well adapted to the risk factors and that full advantage is made of the communities that can inform understanding of the relevant risk factors.^{27, 28}

Finally, the UN resolution provides an important opportunity to improve data and understanding. The resolution calls for the inclusion of drowning within civil registration and vital statistics registers and the aggregation of all drowning mortality data into national estimates. National uptake of this call, along with finalisation and implementation of the WHO Non-fatal Drowning Categorization Framework currently in development, can greatly improve the quality of fatal and non-fatal drowning data. The resolution also calls for countries to share lessons learned and best practices. An increasing number of donors, national governments, and civil society actors are engaging with drowning prevention, and much would be gained by their efforts being thoughtfully developed around the interventions recommended by WHO (which the resolution calls for), closely monitored, and reported in terms of success or failure in the peer-reviewed literature to further enhance the evidence base.

Conclusion

Anyone can drown, no one should. Effective interventions exist that are low in cost and well suited to the LMIC settings where they are needed most. As with many public health issues, particularly multisectoral ones, such interventions require increased awareness, understanding, and support across the sectors involved and the public health community.

The UN resolution is a call to action aimed squarely at the international community; it not only issues a value or moral statement on the tragedy of death by drowning, but also points out the scale of the loss of life and its negative effects on both global development and delivery of the 2030 Agenda. The resolution shows how drowning prevention is relevant to a range of measures to address climate change and reduce disaster risk and, most importantly, it details an array of practical steps that countries, WHO, other UN bodies, and civil society actors can take to reduce drowning. It is crucial that governments will follow up the resolution by implementing interventions recommended by WHO to prevent drowning, that donor agencies will invest in implementing the resolution, that civil society organisations will intensify their important work in encouraging government action, that academia will continue to refine the understanding of drowning prevention, and that the media will keep a spotlight on this silent killer.

Global public health is changing. Collective successes in many traditional public health concerns have unmasked new threats that are becoming leading killers as other causes of death have ebbed. July 25, 2021, is the first ever World Drowning Prevention Day. It is an opportunity to advocate for scaled up investment, programmatic action, and research.

Declaration of interests

We declare no competing interests.