Three Fates of the Malaria-Belt Legacy: Childhood Thalassaemias, Sickle Cell Disease, and G6PD Deficiency, 1990–2023

Thalassaemias, sickle cell disease, and glucose-6-phosphate dehydrogenase (G6PD) deficiency share an evolutionary origin in malaria selection pressure, yet their pediatric trajectories may have diverged under unequal control programs. We jointly analyzed the 0–19-year burden of all three in the Global Burden of Disease Study (GBD) 2023. We extracted deaths, prevalence, and incidence (with 95% uncertainty intervals [UIs]) for the three causes from the GBD 2023 Results Tool—globally, by Socio-demographic Index (SDI) quintile and region—at seven key years (1990–2023), aggregated pediatric age bands into a 0–19-year total, computed key-year estimated annual percentage changes (EAPCs), and examined the 2019–2023 pandemic window. In 2023 the three diseases together caused 39,391 deaths (95% UI 24,456–54,325) at ages 0–19 years—equivalent to 45% of pediatric tuberculosis deaths—with sickle cell disorders contributing 74.6%. Their fates diverged: thalassaemia deaths fell 41.7% since 1990 (mortality-rate EAPC −2.11% per year), whereas sickle cell deaths rose 30.9% (EAPC +0.27%, non-significant). G6PD deficiency affected 168.7 million children (about one in 15) but caused only 1,554 deaths. Sub-Saharan Africa carried 91.8% of pediatric sickle cell deaths, and the low-versus-high-SDI mortality gradient was 66-fold for sickle cell disease versus 8-fold for the other two. The 2019–2023 pandemic window showed no global care-disruption signal. Three malaria-belt diseases met three fates—controlled, stagnating, and silently prevalent. Sickle cell disease, the largest pediatric killer of the three, has been left behind by the intervention architecture that succeeded against thalassaemias; closing the newborn-screening and hydroxyurea gap in sub-Saharan Africa is the defining equity task.