“I’ll really try my best to stop it happening again,” says Shirley, clearly blaming herself for her son Nazario’s near death experience with pneumonia. But Shirley will struggle to keep her promise because no amount of effort on her behalf, or mothers like her, can compensate for the continued lack of government action in the fight against child pneumonia.
This is the Philippines, where 3 million children will contract pneumonia and 12,000 will die this year (UNICEF, 2015). But the same story is being played out in low and middle income countries all over the world where the most vulnerable children shoulder the burden of the 160 million cases of pneumonia and the almost one million deaths that are occuring every year.
Like most mothers raising children on very low incomes, Shirley didn’t know much about the dangers of pneumonia before her son became ill. She did not know that pneumonia was the greatest threat to her son’s survival; a far greater threat than malaria, HIV, diarrhea and measles. She did not know that malnourished children are nine times more likely to die from pneumonia and that air pollution greatly increases the risk of infection. She did not know the telltale signs of fast breathing or chest indrawing, nor how quickly pneumonia could kill her child – within hours. And she did not know that 80% of pneumonia deaths are among children under two years of age even though her son Nazario was right in the danger zone.
Shirley’s lack of awareness about pneumonia is a reflection of the lack of attention governments and the global health community have been paying to the disease for decades. Despite knowing that pneumonia kills more children than any other disease, governments in low and middle income countries and international donors have been spending relatively little fighting it. Less than 2% of all development assistance for health is allocated to pneumonia and 80% of that is for vaccines, leaving little to reduce air pollution, address malnutrition, improve diagnosis and treatment, educate parents and train healthcare providers (IHME, 2014).
Not surprisingly, child pneumonia deaths are falling at a lower rate than deaths from other infections. Between 2010 and 2015 when child measles deaths fell by a stunning 85%, AIDs deaths by 61%, malaria deaths by 58% and diarrhea deaths by 57%, child pneumonia deaths fell by 47% (UNICEF, 2015). There were even several countries that were able to reduce their child malaria and AIDS deaths by more than 60% while child pneumonia deaths actually increased (IHME, 2014).
As a result of this underinvestment, pneumonia causes 16% of all under five deaths globally, with just five countries accounting for half of these deaths – India, Nigeria, Pakistan, the Democratic Republic of Congo and Ethiopia. In a sub-set of countries where conflict and crisis are ever present threats, pneumonia causes more than 20% of all child deaths – Somalia, South Sudan, Eritrea, Timor-Leste, Chad, Haiti and Niger. In fact, more than half of all child pneumonia deaths now occur in settings deemed “fragile” by the OECD (OECD, 2016).
The children most at risk of pneumonia are those exposed to dirty water, poor hygiene and sanitation, air pollution, overcrowding and malnutrition. It is these children who are too often the last to receive the tools available to prevent, diagnose and treat pneumonia. The powerful pneumonia-fighting vaccine – the pneumoccocal vaccine – reaches just 45% of children in the 15 countries where child pneumonia deaths are concentrated (IVAC, 2016). Across these same countries less than half of babies under 6 months old are exclusively breastfed, child stunting rates average 42% and outdoor air pollution is up to eight times the level defined as safe by the World Health Organization (UNICEF, 2016 and WHO, 2016). In fact, some 2 billion children currently live in areas where the air is toxic – 300 million in areas exceeding international limits by at least six times. Of the almost one million child pneumonia deaths each year, more than half are directly related to air pollution (UNICEF, 2016).
This leaves the children most at risk of contracting pneumonia overly reliant on diagnostic tools and treatments that are either ineffective, not functioning, unavailable or too costly. Unlike malaria and HIV, there is no rapid diagnostic test for pneumonia leaving health workers dependent on rudimentary devices like manual respiratory rate counters. Where effective diagnostic tools do exist (e.g. pulse oximeters that measure blood oxygen levels), they can be hard to find…along with the oxygen that can be the difference between life and death for a child that is struggling to breathe. Despite global fears of mounting antibiotic resistance, an estimated 450,000 children die every year because they do not receive an antibiotic (Lancet, 2015).