Lancet: How To Save A Couple Of Million Small Children's Lives A Year

We've made so much progress on AIDS in Africa; now it's time to tackle the world's biggest child-killers, pneumonia and diarrhea.

That's the logic driving a new series of papers just out in the medical journal The Lancet. Here's the summary, and from the press release:

Leading causes of death in children under 5 could be eliminated in 20 years

Diarrhea and pneumonia – regarded as relatively minor illnesses for most people living in high-income countries – are together the leading causes of death for children worldwide. In 2011, they were responsible for two million deaths of children under five, despite the fact that they can be treated and prevented at relatively low cost.

A new Lancet Series on childhood diarrhoea and pneumonia, from a consortium of academics and public health professionals led by Professor Zulfiqar Bhutta of Aga Khan University in Pakistan, provides the evidence for integrated global action on childhood diarrhoea and pneumonia, including which interventions can effectively treat and prevent them, and the financial cost of ending preventable deaths from childhood diarrhoea and pneumonia by 2025.

Dr. Christopher Gill of Boston University's Center for Global Health & Development, who co-authored one of the Lancet papers, offers this (lightly edited) context for the series:

Roll back ten years. Around 2000, there was a big, passionate debate about what we should do about AIDS in Africa. The activists were saying, 'This is a public health emergency, we've got to move. We can do this.' And the skeptics and pessimists were saying, 'This is too complicated and expensive.' The activists won this debate, and today we can look back and say that we have made unprecedented progress on AIDS in Africa. Millions of people are in treatment, there are new drug supply chains and clinics, and the infrastructure is all built de novo. It's spectacular.

So I look at that and say, 'Okay, pediatric diarrhea and pneumonia kills 2 million kids a year, way more than HIV/AIDS does by many fold. The cure for pneumonia, amoxycillin, is widely available and costs nearly nothing to manufacture. For diarrhea, you need oral rehydration salts, sugar and water and zinc. Again, costs almost nothing and is wildly effective. We could cut mortality in half with interventions we've had available for literally decades, and we don't do it. Why? It's not too complicated. We've shown with HIV/AIDS you can take a problem that's highly complicated and solve it in the most difficult situations possible. We have no plausible excuses why we don't do this with diarrhea and pneumonia. We don't need new technologies or vaccines or antibiotics to solve this. We can do it with what we have. If we're not doing it, it's simply because we've made a political decision not to, and I think that's tragic.

So what needs to be done?

Contrast this with HIV/AIDS: We had to develop clinics and tests, largely develop new drugs. What we're talking about here is applying the same lessons in terms of human resources. Let's hire some health workers, give them living wages, train them, make it an attractive job as we did with HIV. Let's apply the lessons learned with HIV about how to get drugs to remote places. Let's use social marketing. It can be done. Let's apply the lesson that it comes down to management more than anything: human resources, supply chains, monitoring. All of these things are what we did in HIV and we could do the same thing for a fraction of the cost.

How many lives could be saved?

The goal is 95% reduction of pneumonia deaths, 70% of diarrheal deaths, so we're talking about saving 1.6 million kids a year. It's an enormous impact.

For how much?

With all the full bells and whistles, $6.7 billion is what we estimated. To cut mortality in half we'd need $3.8 billion. Right now we spend about $14 billion on AIDS in Africa. Right now we don't even have a line item on pediatric pneumonia and diarrhea, it's within newborn health, which has a combined budget for $1.3 billion. So what we're talking about is hundreds of millions of dollars when what we need is a tenfold increase in funds, but still, that is a quarter of what we spend on HIV/AIDS. I'm a passionate supporter of the HIV/AIDS campaign and we've done a stellar job and should celebrate that. The problem is not that we've spend too much on HIV/AIDS, the problem is that we haven't spent enough on pediatric diarrhea and pneumonia.

But has HIV/AIDS taken away from attention to these pediatric killers?

It has absorbed people's attention to an extraordinary degree. I don't know if you can draw a straight line between the two, but indirectly...It has been perceived, rightfully, as the #1 public health emergency of our time, and that has given it the first place in line in every queue. But that is not sustainable anymore when we actually try to think about what we're trying to achieve: To maximize health for the maximum number of people.

This problem is big but we can no longer pretend that this problem is insoluble, because we've definitely shown that where there's a will, there's a way.

The full Lancet series is here. Highlights from the press release:

Pneumonia and diarrhoea account for over a quarter (28.5%) of all deaths in children worldwide, and were responsible for around two million child deaths in 2011, according to new estimates in the first Series paper. Diarrhoea caused around 700 000 deaths in children under five, and pneumonia 1.3 million deaths in the same age group. Over two thirds (72%) of deaths from diarrhoea and over four fifths (81%) of pneumonia deaths are in children under two years old.

The researchers found that sub-Saharan Africa and south-east Asia experienced the highest burden of these diseases, with nearly three quarters (74%) of deaths from diarrhoea and pneumonia occurring in just fifteen countries. Although mortality rates from the diseases are falling in most areas, some countries are still experiencing a growing number of deaths each year, including Afghanistan, Burkina Faso, Democratic Republic of Congo, Cameroon, Chad, and Mali.

According to Professor Robert Black of Johns Hopkins University, USA, "While diarrhoea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, sub-optimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated programme." Mass vaccination campaigns will need to play an important role, and the authors estimate that nearly a third of episodes of severe diarrhoea could be prevented by widespread vaccinations against rotavirus and cholera, with up to two thirds of pneumonia deaths thought to be vaccine preventable.

Series 2: Modest further investment could eliminate diarrhoea deaths in just over a decade

The second Series paper evaluates the evidence for possible preventive and therapeutic interventions against childhood diarrhoea and pneumonia, and identifies 15 key interventions – including vaccinations, zinc supplementation, and breastfeeding promotion – which have the potential to save millions of children's lives. The authors estimate that if these interventions continue to be implemented at current levels in 75 Countdown countries, around half of all child deaths due to diarrhoea and pneumonia could be prevented by 2025, at a cost of US$3.8bn.

However, if these interventions were scaled up to 80% coverage or more, deaths from diarrhoea could be effectively eliminated (95% prevented), and around two thirds (67%) of deaths from pneumonia prevented by 2025, at a total cost of US$6•7bn – less than a quarter of the estimated cost of the 2012 London Olympics .

Series 3: Diarrhoea and pneumonia remain low on list of worldwide priorities, despite huge global impact

...Scarcely half of children with severe acute pneumonia receive antibiotics, while only a third of children with acute diarrhoea receive oral rehydration salts, and fewer than 1% receive zinc supplements. The authors suggest that one reason why many of the barriers identified remain, despite being relatively easily solvable problems, is that recent child survival investments in low-income and middle-income countries have favoured technically sophisticated, expensive solutions targeting specific pathogens or diagnostic challenges, at the expense of broader-based investments in health care systems. According to the authors, "The solutions to reducing childhood pneumonia and diarrhoea deaths are well within our capacity…[but] the pathway…depends on how we prioritise child survival and the investments we choose to make."

Series 4: Ending all child deaths from pneumonia and diarrhoea by 2035 is achievable

In the final Series paper, Drs Mickey Chopra of UNICEF and Elizabeth Mason of the World Health Organization, representing the Series authors, propose a "bold goal" of ending all preventable child deaths from pneumonia and diarrhoea by 2035. The authors say that this goal is achievable, but will depend on increased international awareness of the scale of the problem, strengthening leadership, and co-ordinated international action and investment.

Further reading on BU Today: Keeping Two Million Children From Dying Each Year