The UN Children’s Fund (UNICEF) and the World Health Organization (WHO) have launched their Global Action Plan for Pneumonia and Diarrhoea, which aims to end preventable child deaths from these conditions by 2025. The launch was supported by the publication of a series of articles in the medical journal The Lancet showing that the tools to accomplish this goal already exist, and that the targets should be achievable at a reasonable cost.
The world has seen a dramatic decline in child mortality over the past 20 years: In 1990, 87 of every 1,000 children died before their fifth birthday; the number is now down to 51. But the drop is not yet big enough to meet the Millennium Development Goal (MDG) on child survival - and pneumonia and diarrhoea deaths are two of the main reasons. These illnesses kill around two million young children a year and account for nearly 30 percent of deaths in early childhood.
WHO and UNICEF have proposed the “aggressive target” of bringing the number of pneumonia deaths in children under age five to less than three per 1,000 and the number of diarrhoea deaths to less than one per 1,000.
But this latest effort comes as global development aid is declining. “The OECD [Organisation for Economic Co-operation and Development] published figures last week showing that there is a 4 percent fall in international aid, particularly in sub-Saharan Africa, and that comes after a 2 percent fall in 2011,” said Richard Horton, Lancet’s editor. “And we are coming to the end of an extraordinary period of consensus over maternal and child health and the Millennium Development Goals. So we are at moment of precarious uncertainty.”
Even so, WHO and UNICEF say the cost of achieving their goal is moderate. An estimated $6.7 billion will be required, and they say there is already money in various funds and programmes, such as the GAVI Alliance and various water and sanitation programmes, that can contribute to the whole.
Straightforward interventions
The Lancet series demonstrates that tackling diarrhoea and pneumonia will be complicated: Neither is a single disease curable by one drug or preventable with one vaccine. Rather, they can both be caused by a range of different pathogens.
Yet some straightforward interventions can combat both.
At the top of the list are good hygiene and nutrition, including exclusive breast feeding for the first six months after birth. Healthy, well-nourished children are less likely to fall ill, and if they do, they are more likely to recover.
Increasing the availability of vaccines for common strains of pneumonia and common causes of diarrhoea will also improve child survival. For example, there are vaccines against cholera and the rotavirus, which cause diarrhoea. Comprehensive measles vaccination could also play a role, since pneumonia is often the result of measles.
And when children do become ill, their parents must be able to seek treatment quickly. The right antibiotics for childhood pneumonia must be available in clinics and hospitals, along with oxygen, wherever possible.
For diarrhoea, the most essential treatment is also the cheapest and simplest - oral rehydration. It cannot cure diarrhoea, but it can stop children from dying of dehydration. If ready-made packets of oral rehydration salts (ORS) are unavailable, a reasonable substitute can be made with salt, sugar and water. Yet the authors found that most children with serious diarrhoea still do not receive ORS, and that its use has declined since the 1980s.
Christa Fischer Walker, of the Johns Hopkins University, told IRIN, “In the 1980s, when ORS was developed, there was a huge push from the international community. Celebrities were involved; you could find countries where they used to get the soccer players to go out there and be on billboards promoting it. But as that money has died out and those educational efforts have died out, ORS has died out as well.”
Old formulations of ORS were also problematic. “It’s not an enormously popular product among mothers,” Walker continued. “It doesn’t taste great. It’s hard to get kids to take it. New efforts with low-osmolarity [low concentration] ORS and flavoured ORS have improved on that, but people haven’t really capitalized on the fact that it does taste better, and it is actually more effective.”
Today, there is a move to package ORS with zinc as a full diarrhoea treatment kit. Zinc shortens bouts of diarrhoea and strengthens the immune system, yet in many countries it is difficult to come by.
In Nigeria, for example, there is only one local producer packaging therapeutic zinc, said Shamim Qazi, an expert with WHO. “The cost of a course of zinc in Nigeria is more than three dollars. The reason is that it’s imported. There are regulations, there are taxes. So then it becomes expensive, and there is low demand. People want to use something to treat diarrhoea, so in more than half of the diarrhoea episodes, they use antibiotics, which is quite unnecessary.”
Private sector participation
Qazi’s example illustrates the broad efforts that will be required to eliminate preventable pneumonia- and diarrhoea-related deaths. Manufacturers must be persuaded to produce life-saving interventions, such as zinc tablets, and these interventions must be available to parents through village stores and private medicine sellers.
Elizabeth Mason, director of WHO’s Maternal, Newborn, Child and Adolescent Health Department, says this is why the UN brought private sector representatives into its Commission on Life-Saving Commodities, which was established last year.
She told IRIN, “They are part and parcel of the working groups. And part of the motivation for businessmen is that if they know that they will have a market, then they will actually have the motivation to produce, because they will be making their profit, even though the profit may be very small for each individual dose.”
Well-coordinated health structures and properly supported staff at the community level will also be essential, said Qazi, “We need to build capacity and raise the skills of health workers, and also motivate them to provide these services. There are fantastic health workers out there who are paid peanuts and do excellent jobs, but we need to do better.”
Above all, every region of the world has countries that have already achieved or are close to achieving the targets.
“What we have looked at is who is moving fastest,” said Mason. “Which countries have moved fastest, and what has their rate of decline been? And if they have managed it, we ought to be able to support all countries to manage this.”
