Dying for air

“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, according to UNICEF. 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 occurring 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, according to the IHME.

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%, HIV/AIDs deaths by 61%, malaria deaths by 58%, and diarrhea deaths by 57%, child pneumonia deaths fell by 47%, according to UNICEF. There were even several countries that were able to reduce their child malaria and HIV/AIDS deaths by more than 60%, while child pneumonia deaths actually increased.

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”, according to the OECD.

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, according to IVAC. Across these same countries less than half of babies under six 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.  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, according to UNICEF.

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/AIDS, 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, according to the Lancet.

If this complacency about child pneumonia continues, countries with high child mortality rates will struggle to achieve the global goal to end preventable child deaths by 2030. African governments especially need to prioritize child pneumonia as they have struggled to drive down child death rates compared to other regions. Further, rapid urbanization and industrial development in many towns and cities will increase already high air pollution rates and overcrowding, while women’s rising participation in the formal labor force will keep breastfeeding rates low, absent specific policies such as paid maternity leave, employer-sponsored childcare, and worksite breastfeeding programs.

But there are lights on the horizon that show governments and the international community are moving to fill the glaring gaps in pneumonia control. The Clinton Global Initiative mobilized United for Oxygen – an alliance of 15 organizations in support of the Government of Ethiopia’s new Medical Oxygen and Pulse Oximetry Scale Up Road Map, the first national plan of its kind and an impressive display of national leadership on an issue neglected by the United Nations and international development agencies. The organizations have pledged to, (a) increase the availability of pulse oximetry screening and oxygen therapy in health facilities, (b) train local staff in the use of the new technologies, (c) establish sustainable financing solutions for the procurement, installation and maintenance of the new equipment, and (d) prioritize pulse oximetry and oxygen access in the policies and guidelines of the Ethiopian health authorities and of the major international development agencies.

Improved access to pulse oximetry and oxygen has the potential to benefit the 3 million Ethiopian women who give birth each year and their newborns, as well as 20% of the estimated four million cases of child pneumonia. Each year 11,000 Ethiopian women die in pregnancy and childbirth, 60,000 babies die in the first month of life and 30,000 children die from pneumonia, according to UNICEF and WHO. Babies who are born preterm, or who contract sepsis or pneumonia early in life are particularly vulnerable, as are women and children in remote communities with little or no access to health services.  Improved oxygen access could reduce maternal and newborn deaths by up to 35%, according to the Lancet.

If successful, the Ethiopian experience would become a best practice model for other governments who are struggling with high maternal, newborn and child mortality and low or no access to pulse oximetry and oxygen. In addition to reducing these deaths, improved oxygen access will also help reduce deaths from cardiac arrest, acute blood loss, pulmonary edema, trauma (e.g. road traffic accidents) and unsafe surgery.

United4Oxygen is also an excellent example of how development projects should be pursued in the new Sustainable Development Goals era.  Start with an ambitious government plan in an area prioritized by the new global goals – in this case child mortality – and build a public-private partnership around its implementation. Then prioritize the assets the government brings to the table (financing, public health system, political leadership etc) and ask external partners to fill in the gaps in such a way that the overall health system is strengthened well beyond the life of the partnership.

This is not the only promising new initiative in child pneumonia. Every Breath Counts, an initiative by UNICEF, Save the Children and 34 more to support ten country governments to end preventable pneumonia deaths shows great promise, and Stop Pneumonia, an online repository of advocacy materials to support the growing movement to end preventable child pneumonia deaths is rallying organizations to join forces around World Pneumonia Day, held on November 12th each year. Companies are increasing their contributions beyond vaccines. Leading advertising agency McCann Health has released the first set of training videos to help health workers identify children with pneumonia and trigger faster and more accurate treatment in partnership with the Clinton Health Access Initiative and USAID.

*Members include Adara Development, Assist International, the Bill & Melinda Gates Foundation, GE Foundation, the Global Development Incubator, Grand Challenges Canada, McCann Global Health, Masimo, PATH, Philips, the Pneumonia Innovations Network, Save the Children, UNICEF, and USAID.

10 JustActions you can take to advance the fight against child pneumonia

1. Watch Shirley and her son Nazario’s harrowing story on “The Struggle to Breath” and share the link with five colleagues.

2. Visit www.stoppneumonia.org to learn how you can support World Pneumonia Day every year on November 12th.

3. Read the Pushing the Pace Report for a fresh take on how countries are progressing (or not) in the fight to end child pneumonia deaths and send to five colleagues in one of the countries where progress is slowest.

4. Read the new UNICEF report, “Clear the Air for All Children” and join the Every Breath Counts Coalition.

5. Watch the Pneumonia Innovations Team video and share with five technology innovators you know.

6. Learn how to recognize the symptoms of a child with pneumonia by watching the McCann Health videos and send to 5 health workers you know.

7.  Support United for Oxygen using  #United4Oxygen on all of your social media.

8. Write an article about what your organization is doing to end preventable child pneumonia deaths and post on your organization website.

9. Use the new media tools to start a petition (e.g. www.change.org), raise funds (e.g. www.kickstarter.com), or lobby elected officials (e.g. www.avaaz.org) to do more in the fight against the #1 infectious killer of children under 5.

10. Join the Pneumonia Innovations Team on LinkedIn and become part of a global movement of champions fighting child pneumonia.