10 November 2017

Kenya: Gasping for Breath - Pneumonia's Deadly Toll

Photo: Gates Foundation
For millions of children, breathing is made extremely difficult due to one disease: pneumonia.

A disease that claims the lives of two children under five a minute worldwide has hit drought-stricken Kenya hard, its spread driven by malnutrition.

The baby lying under a red printed blanket is gasping for air. Her tiny chest is convulsed with the effort of drawing oxygen into her lungs and, as her mother looks on helplessly, her pupils roll back under half-closed eyelids.

Sumea, six months old, from Lodwar, Kenya, is suffering from the disease parents here fear the most: pneumonia. Without treatment, she could be dead in a day or two. In Kenya, one of the worst countries affected by the disease, it claimed the lives of 22 473 people in 2015, almost all under the age of two.

But Sumea, the daughter of a businessman, is one of the lucky ones. Her mother, Fatuma Abdi, brought her to hospital when she began breathing very rapidly, a telltale sign that pneumonia has become life-threatening. In Turkana, a rural county where awareness of the symptoms is poor, her mother's quick thinking helped save her. Only half of children in sub-Saharan Africa with such symptoms are brought to a healthcare facility.

Pneumonia kills two children under five every minute, or almost 1 million a year worldwide: more than malaria, diarrhoea and measles combined, according to research recently published by Save the Children. Yet it can be treated with antibiotics, such as amoxicillin, costing as little as 30p. The report, Fighting for Breath, shows that fewer than 60% of health facilities in Kenya, Tanzania, the Democratic Republic of the Congo and Mauritania have amoxicillin available. In Uganda and Nepal, the figure falls to a quarter of facilities. The charity is calling for cheaper vaccines and action plans by governments to ensure universal access to healthcare.

In the acute ward of Lodwar hospital's paediatric unit, Abdi sits cross-legged on a rubber mattress beneath a jaunty mural of Donald Duck. She gathers her exhausted infant in her arms. A nurse places a face mask over Sumea's nose and mouth; it is attached to a portable nebuliser to help open her airways, before she is given antibiotics.

At Lodwar hospital, Fatuma Abdi holds her daughter, Sumea, while a nurse uses a nebuliser to ease the child's rapid breathing. (Jennifer Huxta, The Guardian)

The effect is immediate and dramatic. Moments later, Sumea opens her eyes. Her breathing quietens and she looks up at her mother, whose face breaks into a wide smile of relief.

"I was so stressed, I was in a panic" says Abdi, 38. "But now, look, the child is happy. She is even looking at me."

In Turkana, an arid region in northern Kenya, close to the border with South Sudan and Uganda, the acute respiratory disease is common among pastoralists who use charcoal and wood fuel for cooking. Here, most children are offered vaccinations for pneumonia. But a severe and ongoing drought affecting the Horn of Africa has led to widespread hunger and malnutrition, which weakens the immune systems of the vulnerable, including babies. The nutrition situation in parts of Turkana remains classified as "extremely critical", and, in total, 3.4-million people are expected to be in need of emergency food aid by the end of 2017.

A mother and her children at the acute malnutrition ward in Lodwar hospital. Drought has led to severe food insecurity, which in turn worsens the risks of dying from diseases such as pneumonia. (Jennifer Huxta, The Guardian)

Already, one child in every four in the country is malnourished, making them more susceptible to disease: a severely malnourished child is nine times more likely to die from pneumonia than one who is well-fed. Worse still, malnutrition makes it more difficult to treat.

"Pneumonia is the highest cause of morbidity and mortality here," says Adrian Kituma, the paediatrician in Lodwar hospital, a 132-bed institution that serves the entire county. "Most are likely to have malnutrition and sometimes rickets and other diseases. But it is pneumonia that brings them to the ward."

Kituma is frustrated by the number of very serious cases of pneumonia he sees. Antibiotics are not given often and early enough at the county dispensary health centres, he says. Neither are Turkana's 1.2 million people, mostly pastoralists, educated in looking out for signs of the disease.

"I would say 90% of people are not aware," Kituma says.

The drought has caused significant losses of livestock in Turkana, where most people are pastoralists and depend on their goats, camels, and cows for milk, meat and currency. (Jennifer Huxta, The Guardian)

A pilot project run by local Save the Children staff in Turkana hopes to address some of these issues. It trains villagers as community health volunteers, diagnosing the symptoms of pneumonia and other diseases as well as encouraging breastfeeding and practices that reduce disease, such as handwashing. The volunteers use a simple but ingenious diagnostic tool already proven in other countries: a set of green and red beads, like a giant necklace, along with a timer, to count a child's breaths. If they finish up with a red bead in their hand, they know the child is breathing too fast and make a referral to the nearest health facility, where antibiotics can be administered. More serious cases are referred to the hospital. The £250,000 project, which began in 2016 in Loima sub-county, has trained 93 volunteers, who have referred 1,000 cases so far.

Indicators suggest pneumonia cases have fallen countywide since the scheme began, although it is unclear what is responsible for the drop. In June 2016, there were 4,152 pneumonia cases in Turkana county; this June, the number fell to 2,555.

But fighting the disease, in the face of the drought and the political upheaval following the country's election troubles, remains an uphill struggle. A nurses' strike in June, which followed a doctors' strike, has crippled Kenya's heath service in recent months.

The strike, caused by a dispute over poor pay and working conditions, has reportedly doubled the maternity death rate. Doctors who spoke to the Guardian estimate deaths from pneumonia have also doubled since the strike began in June. Immunisation rates have fallen and babies are not being vaccinated against TB or pneumonia, they say. Hospital staff expect to see a rise in numbers of cases of both. "I would say mortality of the children admitted with pneumonia has doubled since June," says Kituma.

Children in Lodwar hospital. Four out of eight of the children in the stabilisation unit have severe or moderate acute malnutrition. (Jennifer Huxta, The Guardian)

On the day we visit the hospital, there are two paediatric nurses on duty, for 50 to 60 patients. The nurse who treats Sumea does not want to be named, but says she has volunteered to work because she cares about the children and hopes to be paid when the strike is over, "perhaps after the election".

The other is Peris Nyakundi, one of two nurses funded by Save the Children.

"This month has been hard," says Nyakundi. "Malnutrition rates are still high. That happens when there is no food."

Four of the eight children in the stabilisation unit have severe or moderate acute malnutrition. Their mothers, whose brightly coloured kangas and high, beaded collars mark them out as members of the nomadic Turkana tribe, talk of eating just one meal a day; if two, the amounts are very small. Seline Kebo, 24, whose daughter, Akalapatan, is being treated for acute malnutrition and pneumonia, has two other children at home, both of whom are also malnourished.

"We used to have goats, but they died in the drought" says Kebo. "What worries me most is getting food for the children."

The effects of the crisis are starkly apparent in the village of Kachiemeri, an hour's drive from Lodwar along a dusty, bumpy road, criss-crossed by dry river beds. Sitting on a low-lying trunk of an Acacai tree, Akuwom Atiir, who is not sure of her age, holds her second daughter, Adekei Akokote, in her arms as she talks about how she lost her firstborn to pneumonia. She was determined that her second child, who also developed the disease, would not suffer the same fate. So she took her to be treated at a health centre and, from there, she was referred to Lodwar, where she received antibiotics.

Akuwom Atiir at home in Kachemeri village, Turkana. Akuwom lost a child to pneumonia last year. Her one-year-old daughter, Adekei Akokote, was diagnosed with the disease in August. (Jennifer Huxta, The Guardian)

"She is now doing well," Atiir says. Asked what she eats, Atiir gestures at an Eeng'ol, a wild fruit, lying on the sandy ground, which is chewed for its juice.Beyond that she relies on food aid, provided locally by donors, though she and her husband often go to bed hungry.

"The drought has affected us severely," she says. "Even the livestock is dying because there is no pasture and no water."

Dave Kihianyu, the area programme manager for Save the Children in Lodwar, says that while a massive aid-funding effort by donors, governments and aid organisations averted a famine in drought-affected areas of Kenya, Ethiopia and Somalia back in March, preventing a lot of deaths and saving many families from dangerous levels of food insecurity, the effects remain evident.

"The community here are pastoralists," he says. "During the drought they lost many animals, so restocking them takes a long time. We are in the season of short rains, and if the rains don't last till December, the restocking won't happen and the community will be at risk. We are not out of the woods."

This feature was originally published as part of The Guardian's Global Development project.

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