An article caught my eye in last week’s Lancet. Soofi and colleagues conducted a cluster-randomised controlled trial of community case management of severe pneumonia in children aged 2-59 months in a rural district of Pakistan to try and understand how community health workers might be able to recognize and diagnose pneumonia in this population. Basically, the researchers wanted to know if community health workers, given the proper training, knowledge, and resources could diagnose and treat severe pneumonia in the community. As it turns out – they can, and this might be a viable strategy for other places where referral to higher levels of care is difficult.

This article is significant for a few reasons: First, it highlights the ongoing challenges of treating pneumonia in developing countries. Pneumonia is the leading cause of death in children under the age of 5, accounting for 18% of all under-5 deaths worldwide. Effective, accessible, and timely case management stands to save a lot of children’s lives.

Second, it highlights the fact that relatively simple solutions exist for some of the biggest problems we face in global health. Pneumonia is not a new disease, nor is it a particularly “neglected” one in the same way as other neglected tropical diseases, like leishmaniasis or schistosomiasis. For childhood pneumonia, we have effective prevention and treatment options available, but scaling them up has proven difficult and slow. Vaccines exist that provide coverage against pneumococcus and haemophilus influenzae B, which are thought to cause more than 50% of pneumonia deaths in children under 5. Even treatment options for pneumonia are fairly straightforward: amoxicillin and cotrimoxazole, both of which are drugs on the WHO Model List of Essential Medicines, and part of most NGOs’ and countries’ formularies. More broadly, improvements to the determinants of health – improvements to socioeconomic factors, improving nutrition, and so on – would significantly impact the likelihood that children get sick in the first place.

Put all of this together into a comprehensive package of vaccinations, improvements in the determinants of health, and ensuring that treatment is accessible and available for those children who do get sick, and you have a pretty robust package of health services that could really bring down the number of children who die each year from a preventable and treatable disease.

So, what’s the problem?

In population health, we like to think of health as being a complex phenomenon, impacted by influences at different levels – your health is impacted by the community you live in, the resources available to you to make healthy choices and influence healthy behaviours, as well as the economics and laws that impact what kinds of health options are available to you. Improving population health in a significant way requires what we call “multi-level interventions”: interventions that don’t just address one aspect of health, but rather simultaneously address a range of different health determinants, simultaneously. By intervening at different levels, we look for synergies that fuel change at a higher level and that leads to sustainable improvements.

Childhood pneumonia, like most global health problems, is a problem that has multiple levels of influence, and requires complex interventions to address them:  There are economic drivers of the availability of essential medicines and a sustainable and well-trained health workforce, technological factors that limit the availability of essential technologies, knowledge gaps in how to diagnose and treat different kinds of pneumonia, a lack of awareness of pneumonia as a problem among Western donors, and an absence of reliable systems and networks to provide health services to treat pneumonia.

Over the coming weeks, this blog will explore childhood pneumonia in greater depth, exploring not only the challenges, but also the successes in preventing and treating the disease in developing countries. As Soofi and colleagues (and others) have shown, effective strategies for the treatment of pneumonia in difficult-to-reach populations do exist, and with proper investment and training, these programs can make a significant impact in childhood survival.

I will be traveling to Malawi throughout February to explore how that country has responded to the need to scale up health services for the prevention and treatment of childhood pneumonia. I am traveling with the International Vaccine Access Center from the Bloomberg School of Public Health at Johns Hopkins University, who are working to improve access to pneumonia care in this country. Over the coming weeks, we will explore some of the challenges and highlight the many successes of these programs and really try and understand what works, what doesn’t, and why that is.


Soofi, S., Ahmed, S., Fox, M., MacLeod, W., Thea, D., Qazi, S., & Bhutta, Z. (2012). Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Matiari district, rural Pakistan: a cluster-randomised controlled trial The Lancet DOI: 10.1016/S0140-6736(11)61714-5