Viewpoint

Drowning prevention: turning the tide on a leading killer

David R Meddings, Justin-Paul Scarr, Kelly Larson, James Vaughan, Etienne G Krug

Drowning is a leading killer, particularly of children and young adults, yet has been greatly neglected. Despite Lancet Public Health 2021;
accounting for a higher number of deaths than many other substantial public health issues, drowning has not 6: e692–95
benefitted from the targeted attention it requires, which is particularly tragic because low cost and effective drowning Published Online
July 23, 2021
prevention interventions exist. Therefore, the recent UN General Assembly’s adoption of a resolution on global
https://doi.org/10.1016/
drowning prevention is a historic first, and offers an exciting opportunity by providing a comprehensive framework S2468-2667(21)00165-1
and a practical roadmap that a range of actors and sectors, including governments, can follow to address the challenge WHO, Geneva, Switzerland
of drowning prevention. (D R Meddings MD,
E G Krug MD); International Life
A newly recognised public health issue while collecting water, working, or travelling on water. In a Saving Federation, Leuven,
Belgium (J-P Scarr MBA);
In the past decade, drowning has claimed more than survey of lakeside communities in Uganda,5 young adult Bloomberg Philanthropies,
2·5 million lives.1 Many of those lives lost were of men in boats accounted for more than 80% of drowning New York, USA (K Larson MPH);
children who, during a momentary lapse in supervision, deaths, and a survey of such communities in Tanzania6 Royal National Lifeboat
Institution, Poole, UK
slid unnoticed under the water’s surface. Some of the found that adult fishermen were the most likely group to
(J Vaughan)
lives lost were of fisherfolk, typically because livelihood drown and that drowning mortality exceeded each of the
Correspondence to:
needs drove their decision making in the context of national death rates for malaria, tuberculosis, and HIV. Dr David R Meddings, WHO,
unsafe watercraft and inadequate systems to provide Drowning is also prevalent in HICs. It is the second 1202 Geneva, Switzerland
weather warnings. Some lives were lost during mass leading cause of death in children aged 1–4 years in meddingsd@who.int
casualty events, such as an overcrowded passenger ferry Australia, France, New Zealand, Switzerland, and the
capsizing far from shore, or an open dinghy taking USA, and the sixth leading cause of death for children
several extended families to a neighbouring island and and young adults aged 1–24 years for all HICs combined.1
failing to arrive. Some lives were lost during increasingly Risk factors include absence of supervision and exposure
frequent flood-related disasters, in which entire coastal to water hazards such as swimming pools in young
communities have been devastated by typhoons, children, and the absence of swimming skills in school-
cyclones, or hurricanes. age children.7
The first WHO Global Report on Drowning in 20142 Flood-related disasters can also lead to drowning. Both
provided data using the 2012 Global Health Estimates the number of people exposed to flood hazards and the
and identified several striking facts: drowning was severity of flood-related disasters are increasing, and are
among the ten leading causes of death for people aged projected to grow further, as a result of climate change.8
1–24 years in every region of the world; half of all Floods are the most common type of natural disaster and
drowning deaths occurred in people younger than the leading cause of mortality in disasters, and drowning
25 years; drowning deaths numbered almost two-thirds is the leading cause of death during floods.9
of deaths caused by protein–energy malnutrition; and Climate change is having many effects on human health
more than 90% of deaths occurred in low-income and and the relationship between climate change and
middle-income countries (LMICs).2 According to WHO’s drowning is not limited to flooding. For example, of the
most recent Global Health Estimates,1 in 2019 a total of world’s 60 million people engaged in fisheries or
236 000 people drowned, meaning drowning deaths now aquaculture, the majority are small-scale artisanal
exceed deaths from either protein–energy malnutrition fisherfolk of whom 85% are located in Asia and a further
or maternal conditions. 9% in Africa.10 Ocean warming from climate change is
Crucially, drowning disproportionately affects the poor affecting the growth, reproduction, and survival of fish
and marginalised, who are the populations with the least stocks, thereby diminishing fishery productivity in many
resources to adapt to the risks around them, with rates in regions.11 This is pressuring fisherfolk to fish further
LMICs over three times higher than in high-income afield, meaning longer times on the water in vessels that
countries (HICs).2 Among WHO regions, drowning death might not be suited to the conditions, an identified risk
rates are highest in the Western Pacific region, followed by factor for drowning for one of the most hazardous of
the Africa region.1 Collectively, the Western Pacific and occupations.12
South-East Asia regions account for more than 60% of Several factors create bias towards the under-reporting
global drowning mortality.1 National surveys have shown of drownings. Data-categorisation methods exclude
that drowning can occur anywhere with water, such as deaths by intentional drowning or related to floods or
containers, wells, irrigation canals, and natural water transport by water. Also, the inherent lethality of a
bodies.3,4 A large survey in Bangladesh4 found that 80% of drowning episode means that many victims never reach
drowning in children younger than 5 years occurred a medical facility at which the death could be recorded.2
within 20 m of the family home, whereas older children Data from HICs suggest that such data categorisation
and adults tended to drown farther away and most typically methods lead to drowning rates being under-represented

www.thelancet.com/public-health Vol 6 September 2021 e692

 Viewpoint
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
For more on the UN 2030 academic achievement and decreases in the need for
Agenda for Sustainable special education or retention in grade.20–22
Development see https://sdgs.
un.org/2030agenda
Basic swimming and water safety skills have been
For more on the UN Sustainable
shown to be effective and even more highly cost-effective
Development Goals see than day care at preventing drowning mortality.18
https://sdgs.un.org/goals 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 pro­
gramming. 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
e693 www.thelancet.com/public-health Vol 6 September 2021
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.
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 coor­
dination 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 govern­
ments, 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
www.thelancet.com/public-health Vol 6 September 2021 e694
Viewpoint
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
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, under­
standing, 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
 Viewpoint
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.
Contributors
All authors planned and designed this Viewpoint. DRM prepared the
first draft and all authors provided input into subsequent drafts.
Declaration of interests
We declare no competing interests.
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