Guest post by Kevin Watkins, CEO of Save the Children UK
The world is in the grip of a pneumonia emergency – and, no, I’m not only talking about the coronavirus outbreak that started in Wuhan, China. While public health authorities struggle to contain the potentially lethal SARS-like viral agent – nCoV2019, as it is known – childhood pneumonia is today the greatest infectious killer of children, claiming a life every 39 seconds. Yet the international community has responded to that emergency with little more than a collective shrug of the shoulders.
Perhaps that’s because most people think of pneumonia first and foremost as a threat to the elderly, which it is. Coronavirus, which kills through severe and acute respiratory infection, has reinforced this perception. Most of the victims have been elderly people with pre-existing health conditions. Yet pneumonia is today the single biggest infectious killer of children, claiming over 800,000 lives a year. Most of the victims are under 2 years old. Almost all the deaths occur in the world’s poorest countries.
There is a potentially deadly bridge between the coronavirus outbreak and the invisible crisis of childhood pneumonia. nCoV2019 is highly contagious. The fact that it can be spread by carriers who are asymptomatic makes containment difficult. And while fatality rates are well below those associated with SARS, a large proportion of the people affected appear to require intensive care.
So far, the outbreak has been restricted to China and other countries with highly developed health systems. But if the pathogen spreads to sub-Saharan Africa and countries in Asia with weak health systems, childhood pneumonia fatalities could rise exponentially.
Containment of the new threats posed by coronavirus is critical, but not enough. It is time for the world to end the indefensible neglect of child pneumonia. Unlike nCoV2019, this is not a crisis that crosses social boundaries and national borders. It does not register in investor confidence ratings, economic growth projections or stock market sentiment. Yet for the families of the children at risk, childhood pneumonia is a very real health emergency.
No statistics can capture the human tragedies at the heart of that emergency. Caused by bacteria, viral agents or fungi, this is a disease which attacks the lung’s air sacs, causing them to become inflamed and filled with pus. Children are left – quite literally – fighting for breath. This clip from a Save the Children video will give you a sense of what is at stake.
The good news is that the childhood pneumonia can be beaten. Effective pneumococcal vaccines (PCVs) can prevent non-viral cases – and Gavi, the international vaccines alliance, has financed the vaccination of over 120 million children. With early and accurate diagnosis by a health worker, most cases can be successfully treated with basic antibiotics costing less than $0.50. Even the more severe cases can be treated with higher level antibiotics and medical oxygen. Recent research in hospital settings in Nigeria has found that a combination of medical oxygen and a diagnostic tool called a pulse oximeter, which measures oxygen levels on blood, can cut fatalities by half.
Now for the bad news. While childhood pneumonia deaths are falling, they are coming down more slowly than those for other major killers like malaria and measles. Five years ago, governments signed up for a Sustainable Development Goal (SDG) pledge to ‘end preventable child deaths’ by 2030. On current trends, pneumonia will turn that pledge into (yet another) broken promise, further eroding the already strained credibility of governments, aid donors and international agencies charged with delivering on the SDGs.
So why does the world’s biggest killer of children generate so little action and international cooperation? As I’ve argued elsewhere with Devi Sridhar (open access source here), the professor of global public health at Edinburgh University, the victim profile is part of the explanation.
With malnutrition a major risk factor, pneumonia is the ultimate disease of poverty. Those facing the greatest risks – the rural poor and urban slum dwellers – have a weak voice in setting health priorities. And while the poorest children face the greatest risks, they are the least likely to be immunised, the last in line for treatment, and the most at risk of inaccurate diagnosis. Health survey evidence suggests children with pneumonia symptoms from the poorest 20 per cent are one-third less likely than their counterparts in the richest 20 per cent to be taken to a health provider.
Pneumonia provides a window on the (in)equity of health systems. When symptoms of the disease strike, the poorest households will often delay treatment because they are worried about the cost, or because the nearest clinic is far away. In many cases clinics lack the trained staff and diagnostic equipment they need to provide effective treatment.
There are some encouraging signs to suggest that inertia is giving way to action. This week will see governments, aid donors, researchers, UN agencies and civil society organisations come together at the first Global Forum on Childhood Pneumonia in Barcelona (declaration of interest: Save the Children is one of the convening agencies). The aim is to share evidence and, more importantly, to build momentum behind pneumonia control strategies and drive plans of action intended to turn evidence into the policies that will save lives. New coalitions for change are emerging, marshalled under the Every Breath Counts coalition.
One of the barriers to effective action on pneumonia has been the increasingly anachronistic debate between advocates for ‘vertical’, or disease specific interventions, and ‘horizontal’ approaches aimed at strengthening health systems. The substantive issues at stake are real. All too often, donors talk the horizontal talk, emphasising their commitment to building health systems, but then load resources into disease specific interventions that distort priorities. While the World Bank extols the virtues of health system strengthening, its trust funds heavily skew resources towards vertical interventions.
By the same token, health systems must respond to the diseases that place the poor at risk. The idea that countries can advance towards the holy grail of universal health coverage without addressing diseases like pneumonia, and without breaking the link between malnutrition and wider health risks, is a fiction. The entry point for effective action is primary health care and support for community health workers. Health systems that skew resources towards higher-level facilities, beyond the reach of the poor, will never do more than produce trickle-down benefits.
New research from the Johns Hopkins Medical School (JHMS) for Save the Children has provided compelling evidence for a concerted drive against pneumonia. We asked JHMS to run a projection on lives saved to 2030 associated with comprehensive coverage for seven high-impact anti-pneumonia interventions, ranging from immunisation and improved nutrition to antibiotics and exclusive breast-feeding.
The results are striking. The model (below) projects around 3.2 million lives saved from pneumonia in the decade to 2030. But the same interventions could save another 5.7 million lives from other major killers, including diarrhoea and sepsis. If you want an empirical, evidence-based argument for investment in primary health care, here it is.
For anyone still interested in galvanising action for the 2030 SDG on child survival, the Johns Hopkins evidence also suggests that these community-based anti-pneumonia interventions will close the gap between current trends and the 2030 target. Decisive action on pneumonia could translate the blather on ‘leaving no one behind’ that disfigures SDG debates into policies that reduce social disparities in child survival.
Coronavirus has provided a painful but timely reminder that we are members of a single human community. In our interconnected world a health epidemic that starts in Wuhan can, within weeks, pose health threats from Mumbai to New York. Multilateralism and international cooperation are our only defence.
But the case for multilateral action does not stop with epidemics that cross borders and affect the public in rich countries. Today, pneumonia will kill over 2,000 children. That’s a health emergency – and it’s one we can stop.