Need of the hour: Integrated action
Dr Bernard Olayo
Founder & Chairperson
Center for Public Health and Development
Here’s a story of 3 minutes from the life of this newborn in Kenya. The first 3 minutes.
The baby is delivered after prolonged labor. The battle has left its lungs so tired that inhaling each breath seems like an insurmountable task. The mother is relieved that the ordeal of delivery is over even as she faintly realizes the nurse huddled over her baby. The effort of breathing is too much for the tiny lungs. It gives up. The nurse doesn’t. She mechanically pumps air into the lungs using an ambu bag. She has just 3 minutes to make a huge difference. She knows that unless she can keep the oxygen flow going, the brain will shut down, and 3 minutes is the longest the tiny brain can withstand without oxygen. Can she do it?
We will come back later to what happened to the baby and the nurse. Before that let’s understand why oxygen is such a critical piece in the life and death of children in sub-Saharan Africa. A close look at child mortality numbers shows that the top 6 causes of deaths of children in low-resource settings can be connected to lack of access to oxygen. Oxygen is a drug that has been in use for a long, long time and has been listed an “essential” drug by the WHO for more than 30 years.
One villain: Most wanted
More than 100 years ago, pneumonia was one of the leading causes of death. The world has witnessed a lot of changes since then. Except when you count the lives of children lost to pneumonia. Even today the leading killer of children is pneumonia. Pneumonia killed nearly 1 million — 920,136 to be exact — children under the age of 5 in 2015. Half of the deaths — 490,000 — are in sub-Saharan Africa. Pneumonia kills more children every year than HIV/AIDS, diarrhea and malaria combined. Strangely, funding to fight pneumonia does not reflect the gravity of the situation. For every global health dollar spent in 2011, only 2 cents went to pneumonia, as per UNICEF reports.1
Two heroes waiting in the wings
Oxygen can be a lifesaver for children suffering from pneumonia, as the drug provides a vital window for children to continue breathing till advanced treatment takes effect. Most often, young pneumonia patients just stop breathing because of weakened lungs and not the severity of the infection per se.
In 1887, Dr George Holtzapple2 used oxygen to treat a young patient suffering from pneumonia. It was probably not the first such instance but it is the first documented one. Anyway, that’s not the point. One would think that 130 years on it would be common to see children suffering from pneumonia hooked up on oxygen. After all don’t we have oxygen bars today offering strawberry and mint flavor of the drug to anyone who wants to “de-stress"?
The plot thickens
The reality check throws up a different picture. While oxygen wall outlets are taken for granted in any health facility in a developed country, it is a far cry in the developing nations. Nurses and doctors in about 25% of health facilities here do not even have the option of administering oxygen, as it is never available. Their colleagues in 32% of facilities can briefly contemplate about putting the child on oxygen but will most likely be forced to reconsider — either the cylinder is empty with no idea when it is going to be refilled or there is a power outage and no way of using the oxygen concentrator machines.
Costly and irregular supply of this essential medicine has been dogging the public health system for a long time. At the Center for Public Health and Development – a local NGO based out of Nairobi Kenya, we have been addressing the 2 challenges by bringing oxygen closer to health facilities thereby reducing prices by enormous margins and making the drug readily available. This is achieved through local production using one plant that can meet the needs of between 50-80 health facilities within a radius of 100 miles or a rural population of 3-5 million.
It is not only oxygen that can be a bridge to survival for children suffering from pneumonia and respiratory diseases. Just as oxygen can keep children breathing for medications to take effect or simply take the pressure off overworked lungs to leave the body with one less battle to fight, simple devices such as CPAP (or Continuous Positive Airway Pressure) are a life support for low-resource settings. A clinical trial in Malawi has demonstrated that neonatal survival can increase by 27% on application of CPAP3. Both oxygen and CPAP are critical interventions to ensure there is sufficient oxygen in a child’s body to provide sufficient time for medications to address the underlying causes of a child’s illness. Because of this, oxygen and CPAP form a bridge to survival for children under years. CPAP and oxygen go hand in hand with proven evidence that oxygen lowers mortality in pneumonia.
Our success with introducing CPAP at county-level public hospitals in Kenya has encouraged other public hospitals to come forward and apply this low-technological non-invasive approach to tackle the high number of deaths in the pediatric ward. A combination of these two solutions has proven to be very effective in reducing mortality for premature neonates – a group that continues to experience very high mortality despite all the interventions currently in place.
All this is fine until we start calculating how fast we need to move forward to effect a substantial change in child mortality figures. We have 13 years to meet the SDGs. To make this happen the current trends need to be accelerated across all developing nations, and especially sub-Saharan Africa. It will take the region another 20 years beyond the SDG targeted time, till 2050, to meet the neonatal and under-5 targets if it continues to progress at the existing rate, as per the calculations of the United Nations Inter-agency Group for Child Mortality Estimation4.
As we observe yet another World Pneumonia Day on November 12, it is imperative we tackle the deadliest cause with the maximum rigor. It can be a long 13 years to 2030, or a short one, depending on how well we utilize this time to get our act together — the operative word here being “together”. It is a fight that needs the coming together of visions and radical actions. For example, if we can ensure CPAP is available off-grid and combine it with the potential of oxygen therapy, make oxygen as easily to access as a bottle of milk, it can pave the way a greater penetration into hard-to-reach areas of neglect. All our babies deserve a chance live, and our healthcare workers the essential tools to save lives.
Which brings us back to the baby in Kenya fighting for each breath. Did the nurse win the race against 3 minutes on the clock? Did the baby live? Well, it is an ending we are still working on. On a typical day it will end with the baby dying and the nurse tucking away another gut-wrenching moment in her memory. We are hoping it will be an atypical day. A series of fortunate events and small victories if we are able to bring the double solutions of Oxygen and CPAP where they are needed most.
ABOUT THE AUTHOR
Dr Bernard Olayo is a physician, public health advisor and a social entrepreneur working for more than 14 years in maternal and child healthcare in Africa. He is the founder of the Center for Public Health and Development, which is a non-profit organization. He has also launched two successful social enterprises on oxygen access and medical equipment — Hewa Tele and MediQuip Global, all with the objective of improving access to quality and affordable essential healthcare. He has been recognized as one of the “Hidden Heroes” and as one of the top 10 innovators in the global fight against pneumonia.
2. Shultz SM, Hartmann PM. George E Holtzapple (1862-1946) and oxygen therapy for lobar pneumonia: the first reported case (1887) and a review of the contemporary literature to 1899. J Med Biogr 2005;13(4):201-206.
3. Kawaza K, et al. E Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi. PLoS One. 2014 Jan 29; 9 (1): 2014.
4. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), as published in UNICEF: Committing to Child Survival: A promise renewed-Progress report 2015, UNICEF, New York 2015)