Leith Greenslade, founder of Just Actions and coordinator of the Every Breath Counts Coalition, discusses why childhood pneumonia remains the world's leading infectious killer of children despite being preventable and treatable. Drawing on her experience across major global health institutions and her groundbreaking advocacy during COVID-19, Greenslade reveals the systemic failures that have kept pneumonia in the shadows and charts a path forward as the world moves toward the 2030 deadline for achievement of the Sustainable Development Goals.
The episode opens with Leith Greensalde recounting her journey from rural Queensland to international global health work. After starting her career as a political adviser to senior Labor politicians including Brian Howe, she moved to the United States for graduate study at the Harvard Kennedy School prior to Labor's anticipated 1996 election loss. Following a brief and unsatisfying return to work with Labor in opposition, and business studies in Hong Kong during the handover to China, she eventually settled in New York to work in global health during what she describes as the "golden era" of funding and institution-building in the 2000s.
Her work with major institutions including the Gates Foundation, Gavi and the Global Fund gave her a front-row seat at the creation of the modern global health architecture but also left her frustrated by what she saw as narrow focus and bureaucratic limitations. This led her to found Just Actions, a platform focused on ten high-impact but neglected issues, with childhood pneumonia as the flagship cause.
Leith explains that pneumonia has been the leading infectious killer of children for decades, claiming approximately 500,000 lives annually — more than HIV, malaria, and tuberculosis combined. Yet it has consistently been overlooked by global health agencies and funders. She attributes this neglect to several factors: children in low-income countries who are most affected have no political voice, the disease has multiple causes with no single solution, and unlike other major diseases, pneumonia lacks a dedicated global fund or agency to coordinate efforts.
The conversation explores the multiple barriers children face throughout what Leith calls the "pneumonia journey." Many families do not recognise the symptoms or understand the urgency of seeking care — in many countries there isn't even a word for pneumonia. When children do reach health facilities, diagnosis is difficult without rapid tests that can differentiate bacterial from viral pneumonia. Essential treatments like amoxicillin dispersible tablets (child-friendly antibiotics) and medical oxygen are frequently unavailable due to market failures and the absence of coordinated procurement systems.
Leith's advocacy during the COVID-19 pandemic brought the issue of medical oxygen to global attention. She describes families across Latin America, Asia and Africa being forced to source oxygen on black markets while the global health community was slow to respond. Her work with the Every Breath Counts Coalition and the subsequent Lancet Global Health Commission on Medical Oxygen Security revealed that 70% of people worldwide who need oxygen do not receive it — a gap far greater than for other essential medicines like HIV/AIDS or malaria treatments.
The discussion turns to regional issues, with Leith noting that Asia is actually the worst-affected region for respiratory conditions when including India, driven by pollution, crowding and smoking. She acknowledges the particular vulnerability of Pacific Island countries, which experienced oxygen shortages during COVID-19, while praising the support provided by the Australian government and universities in the region. She highlights the work of Professor Fiona Russell at Murdoch Children's Research Institute as an exemplary case of Australian leadership in pneumonia prevention.
Despite the challenges, the conversation includes discussion of promising innovations. New RSV vaccines and monoclonal antibodies could potentially eliminate RSV as a childhood killer, while WHO's recent Integrated Lung Health Resolution represents the first coordinated approach to addressing both infectious and chronic respiratory conditions together.
The episode also examines the current global health funding crisis, which Leith views not as a catastrophe but as an opportunity for necessary reform of what she sees as an unsustainable system built in the 2000s. She argues that the proliferation of large international organisations created inefficient “middleman” layers while fostering unhealthy dependence, particularly in African countries where entire health systems became reliant on external funding. The current constraints may force more effective prioritisation and potentially allow countries to regain greater control over their health systems.
Leith remains optimistic about achieving the Sustainable Development Goal of ending preventable child deaths by 2030. She notes that global child mortality has already halved from 12 million to 5 million deaths annually, and believes that with focused effort on diseases like pneumonia that kill the most children, the world could achieve what she describes as guaranteeing the survival of most children regardless of where they are born — something our species has never accomplished before.
Devpolicy Talks is the podcast of the Australian National University's Development Policy Centre. Our producers are Robin Davies, Amita Monterola and Finn Clark. You can read and subscribe to our daily blogs on aid, international development, and the Pacific at devpolicy.org. Follow us on Facebook, LinkedIn, Instagram, and Twitter. Send feedback or episode ideas to devpolicy@anu.edu.au. Join us again in a fortnight for the next episode of Devpolicy Talks.
Resources and Further Reading
Lancet Global Health Commission on Medical Oxygen Security
World Health Assembly Integrated Lung Health Resolution (2025)
Leith Greenslade (excerpts):
The care seeking rates for pneumonia are really low. 40% of children with pneumonia symptoms are never taken for care, 40%. … When you look at a lot of the survey data in many countries, there still isn't a word for pneumonia. … It's the largest infectious killer of children, and it has been for decades. It kills many, many more children than things like malaria and HIV/AIDS and diarrhea and measles. … We will have a world where it's extremely rare everywhere for a child to die before they turn five. That'll be the first time, as a species, we've been able to guarantee the survival of most of our children, no matter where they're born …
Amita Monterola: We wish to acknowledge the indigenous people of Australia, the wider Asia, Pacific region and other parts of the world, and express our respect for their traditional knowledge and practices, which stem from a deep connection to the lands and waters they have inhabited for millennia.
Robin Davies: Welcome to Devpolicy Talks, the podcast of the Development Policy Centre. We're part of the Crawford School of Public Policy at the Australian National University, on Ngunnawal and Ngambri country in Canberra.
I’m Robin Davies.
This is our twelfth season, and we’re bringing you a mix of interviews, event recordings, and in-depth features on topics central to our research – including Australia’s overseas aid, development in Papua New Guinea and the Pacific, and broader regional and global development issues.
This episode is about childhood pneumonia, a disease that kills more children than HIV, malaria and tuberculosis combined, yet receives relatively little attention from policymakers and the public. Pneumonia claims about 500,000 children’s lives each year despite being both preventable and treatable with existing tools like vaccines, antibiotics and medical oxygen. While children in wealthy countries have been protected by pneumonia vaccines since the early 2000s, millions of children in low-income countries still lack access to these interventions.
To help us understand why this gap persists and what can be done to address it, I'm joined by Leith Greenslade, an Australian global health leader whose career has taken her from advising respected Labor politicians like Brian Howe, Kim Beazley and Jenny Macklin, to working with global health institutions including the Gates Foundation, Gavi and the Global Fund. After becoming frustrated with the limitations of large organisations, Leith founded Just Actions, focusing on ten high-impact but neglected issues, with childhood pneumonia at the forefront.
As coordinator of the Every Breath Counts Coalition — a global alliance of more than 100 organisations spanning UN agencies, governments, foundations and academic institutions — Leith has built the world's first dedicated advocacy platform for childhood pneumonia. The coalition represents a unique response to what she calls the "advocacy gap" for diseases that primarily affect children in low-income countries, who have no political voice and whose deaths rarely make headlines in wealthy nations. Under her leadership, the coalition has worked to establish pneumonia control strategies with national governments, develop global indicators for measuring progress, and coordinate international efforts to address market failures that have left essential treatments out of reach.
Her work took on new urgency during the COVID-19 pandemic, when Leith led what she describes as the hardest advocacy campaign of her career. As images emerged of families across Latin America, Asia, and Africa desperately seeking oxygen on black markets while hospitals turned patients away, she was struck by the global health community's initial failure to respond to the crisis. Her relentless advocacy, working with coalition partners, eventually secured international attention and resources — but a year too late to prevent countless deaths from oxygen shortages. This experience led to her co-chairing the Lancet Global Health Commission on Medical Oxygen Security, which revealed the shocking scale of the problem: 70% of people worldwide who need medical oxygen don't receive it, compared to just 25% for HIV/AIDS and malaria medicines.
In our conversation, Leith explains why pneumonia has been overlooked despite the immensity of the disease burden, describing the multiple barriers children face from initial symptoms through to treatment. These include low awareness among families, the absence of rapid diagnostic tests, and shortages of child-friendly antibiotics and oxygen in health facilities. We discuss how market failures have left essential treatments out of reach, why the global health architecture built in the 2000s focused narrowly on specific diseases while neglecting pneumonia, and what the current funding challenges mean for reform.
Leith also discusses innovations like new RSV vaccines, the regional burden of pneumonia in Southeast Asia and the Pacific, and why she remains optimistic about achieving the Sustainable Development Goal of ending preventable child deaths by 2030.
Leith Greenslade: My name is Leith Greenslade. I'm Australian, but I've lived in New York City for a very long time. I do a lot of global health work, wearing various different hats but I'd say mainly it's maternal and child survival focused work, with the exception of COVID, where we really, I think, played a very distinct role. I'm sure we'll talk about it.
Robin Davies: I'll focus a lot of the discussion on childhood pneumonia causes and treatments. But just before we do that, you've had a very interesting career path, working initially with some storied politicians here. I think they've all retired from the political scene by now. Brian Howe, Kim Beazley, Jenny Macklin — how did you get from that sort of role, the political advisory work, and it was not just in health, how did you get from there to the sort of work you've been doing in the last few years?
Leith Greenslade: Well, I left Australia. I was working for Brian Howe, and he was towards the end of his sort of career. I got the end bit of Brian, but honestly, I would have taken anything — he was an extraordinary politician. So, I worked for him from about 1990 to 95, and it became very clear that Labor would lose the election — the 1996 election. Paul Keating was head of the government, but the writing was on the wall. So, I left to do a graduate degree at the Kennedy School in Boston. So that was my sort of exit. And then soon after I started that master's degree in public policy, Labor lost the election, which was devastating to me, but I think we all knew that was coming.
So, then I had to think, what am I going to do? Am I going to build a career abroad, or go back, or what? And to be honest with you, I come from Queensland. I grew up in rural Queensland, so even going to Canberra was a very big step for me. It's a big world. So, the idea of having a career outside of Australia at that time was just a bridge too far for me. So, I did the degree, and I came back and worked for Labor in opposition, which was a disaster. Honestly, for me, it was awful. Labor was a shadow of its former self. A lot of the politicians of the Hawke-Keating period were exemplary, I mean, stellar individuals, real reformers. They were all gone. So that was very difficult time.
So, I thought — and I think even just two years in America, it's very different environment in America, just two years there had sort of sparked something in me about the sort of global stage, still very much focused on politics. So almost as soon as I got back to Australia and realised that this was not going to be a good experience, Labor in opposition, I was sort of trying to get out. And then eventually thought, okay, I only have public sector experience. I need some business experience. And I went to Hong Kong and did a master’s in business administration for two years, and this was just after the handover — so fascinating — to China. So, it's a fascinating time to be in Hong Kong and watch this thriving, democratic city start to transition to China. I mean, that hasn't gone well for poor Hong Kong, but at that time, it was still a very, very vibrant city. And then eventually came back to the States. It's sort of — it was like a magnet. It lured me back, and I've been here ever since, working in, I guess, public policy and leaving behind politics, which I always, from time to time, regret, actually.
Robin Davies: And so most recently, you founded the organisation, Just Actions. What led to that?
Leith Greenslade: So, when I came here, this was the 2000s, and people talk about that as the golden era of global health. You had Bill Gates who was just setting up the Gates Foundation, and this tsunami of money from the foundation, but also from governments, the US government, European governments. It just flooded into global health. And global health was really built in the 2000s with Gavi, the Vaccine Alliance, the Global Fund for AIDS, TB and malaria, UNITAID came a little bit later. They were all built at this time with all of this money. So, I came here right at that point. So, I worked for many of those organisations between 2000 and 2016. But after more than a decade, I was very jaded working for a lot of these big organisations. I wanted to just go out on my own and see if I could just sort of have the luxury of picking and choosing who I worked with and what I worked on. It was a big risk to take. But honestly, as anyone that's worked in large bureaucracies knows, some people, and I think I'm one of them, you can only take so much. I'd had enough, so I created Just Actions, which is just my little sort of home base where I can pick and choose who I work with. That's worked well for the last — what is it now — nine years.
Robin Davies: And what's the scope of work of the organisation?
Leith Greenslade: So, I looked back over all the things I'd worked on when I set up Just Actions, and thought, okay, what are the 10 areas where I think focused action would move the needle more than anything else. So, it's almost like my take on the sustainable development goals. We have 17 of those, but that's a lot. They're all over the place. I think it's probably too many. And I just wanted to filter down, okay, the 10 things that really could change all the things in the world that I can't stand and have never been able to stand, the inequalities, the deprivation experienced by some just because of where they happen to be born, the sort of lottery of life that we're all trying to fix in one way or another, if you work in this area. So, I picked 10, and you can see what they are, and so I only work on those 10 areas. So, people do come to me sometimes and say, would you do this or that? It has to — I'm very focused on these 10 areas, and I only do work in those 10 areas.
Robin Davies: Is the choice of priorities in part driven by where you see gaps in the international architecture?
Leith Greenslade: Oh, totally. So, people ask me about this all the time, like, why don't you work on the stuff where there's lots of money, or why don't you work on the stuff where there's really good people already doing it? Not interested. And I do sometimes wonder why, and I do wonder if it's this Australian thing of the underdog, which still sits strongly with me — areas that are neglected for no good reason, groups that are ignored because they may not have powerful advocates. That's where I like to be. So, I have picked areas where there's been a huge need, but for whatever reason, we can talk about why, no one's been paying attention to them. And I guess the flagship there is childhood pneumonia, where I've worked consistently ever since I left Australia.
Robin Davies: And just before we do start to talk about that, how is all of this work funded and supported?
Leith Greenslade: So, I have to go out and raise that money. So Just Actions, it's a company, but I have to go and build those contracts with clients and partners. So, a lot of the work I do is with the Gates Foundation, where I might put a proposal to them, and they green light it, and then pay me to go and do that and build a team. But I've, over the years, worked for UN agencies, I've worked with companies, although that's its own special challenge, but I do that. And small NGOs, large NGOs, I'm always looking for partners that have funding capacity, but that I'm also sort of aligned with.
Robin Davies: Well, let's talk about childhood pneumonia. Perhaps, maybe, could you just give a quick overview of the scale of the problem and the main causes of the problem before we start to talk about some of the responses?
Leith Greenslade: Yeah. So, it's the largest infectious killer of children, and it has been for decades. So, it kills many, many more children than things like malaria and HIV/AIDS and diarrhoea and measles, things that everyone can talk about, but they don't. I think there's still not a lot of awareness that pneumonia is this massive killer, and we just haven't had groups concerned about that. I'll give you good examples. So, we have some great vaccines to prevent pneumonia, really good vaccines that kids in America and Australia and Europe have been getting since the early 2000s. Gavi didn't prioritise those vaccines. We can talk about why, but it took them — they're only just — the pneumonia vaccines are the lowest coverage of all the childhood vaccines when pneumonia is the leading infectious killer.
Robin Davies: That’s the pneumococcal conjugate vaccine, the —
Leith Greenslade: The pneumococcal vaccine, the Hib vaccine, the beautiful vaccines, they were just sort of not prioritised. I could never figure out why, and then I had to wake up to the fact that our wonderful global health agencies do not prioritise their work according to disease burden. There are many other factors that go into it. So, deaths are coming down, but we're still losing about 500,000 children every year from pneumonia, 500,000. These deaths now are fairly concentrated in Africa and Asia. So, we know exactly where these children are dying. It's not only a vaccine solution. There are many other challenges around pneumonia, but we just — until we can sort out pneumonia, we can't achieve this wonderful sustainable development goal we have for child survival, the SDG 3.2, which motivates most of my work. And it's actually, if you hear Bill Gates talking about the Gates Foundation, he always goes to the child mortality rate as sort of the one data point that obsesses him and the foundation, and then pneumonia being the leading infectious killer, you can't solve child mortality without zeroing in on pneumonia. So, it's always been very motivating for me to try and do as much as possible to zero in on pneumonia. We created a whole coalition, the Every Breath Counts Coalition, which I lead, which now has more than 100 organisations totally created just to take on pneumonia, because nobody else was doing it.
Robin Davies: It is quite striking that when you look at the statistics, childhood pneumonia is right up there with HIV/AIDS, malaria, tuberculosis, in fact, worse in a couple of cases of those diseases. Why do you think it has not received the same level of attention?
Leith Greenslade: When they created the Global Fund, which I think is our — the Global Fund for AIDS, TB and Malaria, which is our largest in terms of funded global health agencies. It's done enormously good work. If you look at the curve on HIV/AIDS, it's a beautiful curve. You see it rocketing up and then bends and comes down. And that's deaths, HIV/AIDS deaths, and that's largely because of the Global Fund and PEPFAR out of the Bush administration, so not to detract at all from their extraordinary work, but whenever that was set up, why those three? Why did they leave out pneumonia? When, even when the Global Fund was being set up, it was killing more people than even than AIDS. Why did they leave pneumonia? I've asked that question of all the key players who set up the Global Fund, and the closest I've got to a good answer is “we didn't know”, which is probably close to the truth, because a lot of these experts or the — when these things are set up, it still strikes me how many of the political decision makers, they just don't know their global burden of disease data, which is shocking to me, but a lot of them don't.
So, one of my — I mean, I love the data. I'm — we're all always data driven. In any work I do, it's always data, and we have good data now in global health. There's no excuse to be spending money on things that really don't affect that many people and then ignoring the things that affect hundreds of thousands of children.
Robin Davies: Would it be unfair to suspect that the big three diseases that are addressed by the Global Fund each caused by a single pathogen, which at that time, there were no useful vaccines except for the TB childhood vaccine, and there was hope that over time, there would be a silver bullet in the form of a new vaccine for each of those things. So single pathogen, hope of vaccine, and those things were not there for pneumonia. Do you think that might have been part of the thinking?
Leith Greenslade: Well, your argument makes sense, but I don't think so. Someone else said to me once, so it's because pneumonia kills children disproportionately, whereas malaria kills a lot of kids too, but it also affects a lot of adults. And AIDS is basically adults, and so is TB, so you have strong adult constituencies around advocacy, particularly HIV/AIDS was phenomenal advocacy. Lobby in it. I mean, just phenomenal. They wrote the playbook on global health advocacy. But for pneumonia, children can't advocate for themselves. And most of these kids that were dying of pneumonia, they don't die like in rich countries. I mean, AIDS killed a lot of—it was when AIDS started killing Americans that really actions started happening. That's not the case with pneumonia. It's been a childhood killer in poor countries. So, I think there are explanations, but there's been plenty of time to correct that early mistake, but we don't have a good alignment. I mean, this is the big criticism of global health, is that the architecture that we built with all that money in the 2000s went very deep in very few areas. So, we got the three diseases from Global Fund. We got some vaccination from Gavi, and that's pretty much it. It went very deep. But what about all the rest of it? Nothing really.
Robin Davies: Hence the term “vertical fund” which you don't hear quite so often these days. But yeah, so, I mean, there's always been a sense that TB is the poor cousin among the big three diseases. But in fact, pneumonia really is. I mean, maybe, could you just for people listening, could you just run us through what are the principal causes, given that there are multiple causative agents and aggravating factors in the case of pneumonia, what are those principal causes of pneumonia?
Leith Greenslade: So obviously lack of vaccination. When a child's not vaccinated, they're going to get sick. But the care seeking rates for pneumonia are really low. So, 40% of children with pneumonia symptoms are never taken for care, 40%. Now, why is that? So, when you look at a lot of the survey data in many countries, there still isn't a word for pneumonia. It's not an identifiable disease like malaria. So, you talk to families, and they'll have some language for the symptoms, their child's exhibiting cough and fast breathing and fever. But they won't have a — they won't say, oh, we think that might be pneumonia, we better get to the doctor, because that thing kills really quickly. So, we've failed to really advocate around raising awareness that pneumonia is a condition, that it's dangerous. These are the symptoms, and it can kill in 48 hours if you don't get that child to a clinic. So that's one thing.
Now for the kids that do get to the health centre, there's no easy way of diagnosing pneumonia. We don't have a rapid diagnostic test for pneumonia like we do for malaria. So, all that the WHO recommends clinicians do is count respiratory rates, like with human brain, which is fraught with error, and try and decide whether this child has pneumonia or not. We don't know if it's viral pneumonia. We don't know if it's bacterial pneumonia. We don't have that rapid diagnostic test. So, this is the holy grail of childhood pneumonia. We need a rapid diagnostic test that can differentiate bacterial and viral.
Now let's say you get a diagnosis. You jump all through the — you get to the centre, you get a diagnosis. Still, many of the health facilities don't have the recommended antibiotic, which is the amoxicillin dispersible tablet. It's a special little, nice, little antibiotic that dissolves for a child. They certainly don't have medical oxygen. A lot of these kids need oxygen. There's no oxygen. So, if you look at every step along the sort of pneumonia journey, the kids are really vulnerable. Does mum and dad know this is what I've got? And get me to the facility. Can the facility diagnose me and see if they can? Are they going to have an antibiotic or oxygen? I mean, it's a really vulnerable journey for a kid that gets pneumonia in a low-income country.
Robin Davies: And within the categories you talked about, bacterial and viral pneumonia, even there, there are multiple possible pathogens at play, and I assume the treatments that will be effective will depend on correct identification of the specific pathogen. Right? Exactly, yeah. So, we're seeing a lot of RSV circulating these days. So, you could be talking about something that's caused by RSV or something that's caused by a range of other viruses. So, looking at the treatment options, you referred to one of the most important, the antibiotic amoxicillin dispersible, which is specifically formulated for kids. How widely available is that treatment in developing countries?
Leith Greenslade: No, it's not widely available. WHO and UNICEF have been recommending it forever, but you still, if you go into countries, you'll find the old cotrimoxazole syrup, or you'll find an amoxicillin for an adult that the tablets that the child can't chew. Or you'll find an amoxicillin — I mean, it's not — I can't say that our global health agencies, once they're very good at recommending a product that's good, but then translating that into uptake, it's just not what they're good at, because that's a market, that's a market solution. I mean, the companies that make their pharmaceutical companies make those technologies, they have to be persuaded to be in these markets, the price has to be right. All that side of things I find since I've worked in global health, working with the companies, I think Gavi and the Global Fund are the only ones that have really got that right. So Gavi has been able to work with big pharma very effectively on lowering vaccine prices. And Global Fund as well for the AIDS, TB, malaria bed nets and the medicines, I guess because they've got buying power, but we've never had that in pneumonia. We've never had a big agency that's able to work with the amoxicillin manufacturers. And we still don't have that.
Robin Davies: Yeah, so there's no international agency whose job it is to do market shaping and procurement and distribution of antibiotics. It's a huge gap. Yeah, and what about other treatments, depending on what's required, but antivirals, we'll come to oxygen in a moment. But what about other pharmaceutical treatments? Is it a similar picture?
Leith Greenslade: Well, there isn't that much, really, so that's needed for a viral — a lot of the kids. One of the problems is, a lot of the kids with viral pneumonia are getting an antibiotic which they don't need. So, you know, the viral pneumonia, most kids will survive it, with the exception of something like RSV, which you just mentioned. But the exciting thing about RSV is we've just got these two new preventive tools, the maternal vaccine for RSV, which is very exciting, and there's new monoclonal antibodies, which is one injection a baby would get just after birth to protect it. So, RSV, if we can get these tools out, and this is a big priority for the Gates Foundation, it's part of my work at the moment, if we can get these new RSV tools out to low middle-income countries, RSV will also be a thing of the past. Kids won't get it anymore. It'll be prevented. So, and that's a maternal vaccine and a monoclonal antibody. So, there's still a lot of innovation left in the pneumonia pipeline. I'm very excited about the RSV tools.
Robin Davies: So, on the vaccine front, there are several relevant vaccines. Now you've talked about the pneumococcal conjugate vaccine, the Hib vaccine, and now these newly emerging RSV vaccines. What can we expect in particular, from Gavi in relation? They're already distributing the pneumococcal, but —
Leith Greenslade: No, oh yes, big time. In fact, pneumococcal vaccine is one of the — it's, I think, most expensive vaccine they — that Gavi works with. It takes a huge proportion of the Gavi budget. RSV is on their list, but they have a lot. Gavi has a huge list of vaccines that they're expected to be supporting, the malaria vaccine, that the new malaria vaccine, they're supporting that very aggressive roll out. So, RSV is on their list. But of course, Gavi is out in the public domain trying to raise a huge amount of money. Right now. They're not getting it because of what's happened with global health financing. So, I'm expecting Gavi will have to do what WHO is doing and UNICEF is doing, which they go into a prioritisation, aggressive prioritisation conversation, because I just heard a few days ago WHO is laying off 20% of staff, UNICEF, potentially more. So, these — and that will, Gavi will be affected by this too. So, at the same time as we have all these great new technologies coming through, our global health agencies are getting weaker by the day, so they'll have to prioritise, which means they'll have to go back to disease burden and lives saved and all of that. And I'm confident that, because pneumonia kills so many kids, any vaccine related to pneumonia is going to be very high impact. And I would hope they would prioritise it.
Robin Davies: Yeah, yeah. And of course, we haven't even mentioned COVID. We're talking a day after Robert F Kennedy Jr has decided outside the usual process to cancel the recommendation for COVID vaccination for children and pregnant women. So, it's not just the money. These sorts of things have a flow on effect in terms of sentiment and availability of product as well. All right, so coming to oxygen and oxygen supply has been a huge focus of your work in recent years. Maybe one quick way to come at this is through your work on the Lancet Commission on medical oxygen supply, which has recently reported. You were part of that process. What were the principal findings and recommendations of that Lancet Commission?
Leith Greenslade: So, the Lancet Commission on global — Lancet Global Health Commission on Medical Oxygen Security was two years in the making, and it was really born out of the tragedy of COVID. So, I'm sure people can think back. Maybe we want to block it out, but we can think back to some of those images that started rolling in in the summer of 2020, from Latin America, then it moved to Asia and then Africa, of people standing in line trying to get medical oxygen. The hospitals had run out and were turning patients away, leaving families on their own to find oxygen. Typically, they would have a loved one dying at home because there were no beds at the hospital and they'd be trying to get oxygen cylinders filled on the black market. They were charged exorbitant fees. These stories kept coming into us day after day after day, and we thought, okay, the global health community will respond. There was a group set up to coordinate the international response. All the big names were there, Gates, USAID at the time, Wellcome Trust, Global Fund, Gavi, of course. And oxygen was not something they were discussing at all, Robin, at all. Despite the headlines, you couldn't avoid these stories if you tried, these tragic family stories.
So that was a red flag for me. I thought, wow, what is wrong with our architecture that when we have a major pandemic, where the one thing people need while they're waiting for a vaccine is medical oxygen, and they can't get it, and the global health community can't help them get it. So we began in summer of 2020, this enormous advocacy effort, which is the hardest I've ever worked on, trying to get something on the agenda. Anyway, we ended up being — as a coalition, the Every Breath Counts Coalition — we had everyone working 24/7 on this. We finally got a decent response. But it was a year too late, and many people died. Many people in those COVID death numbers died for lack of medical oxygen. They suffocated to death.
So, when everything calmed down, we thought, okay, we have to have a reckoning of why this happened. How could this have happened so that it never happens again? And that was the origin of the Lancet Commission. We went to the Lancet Global Health and pitched that idea, and they said, okay, go for it. It was only their fourth commission that they've ever done.
So, we put together a team which was heavy with Australians. I have to say, there's some extraordinary Australian academics that have been working in this area for many, many years. Trevor Duke, I think, is often the sort of—everyone traces back to Trevor.
Robin Davies: Yes, he did good work in Papua New Guinea and Pacific. Great work.
Leith Greenslade: A lot of his early scholarship we relied on to make the case for why this would be a great investment. And then he sort of sparked a great group of younger — Hamish Graham was one of them, Amy Gray, but there's several of them just terrific. So, we all got together and formed a big group, big global group, and thought, okay, let's understand what happened. Let's get some data, some numbers, because no one had any numbers. WHO had no numbers on oxygen needs or gaps or anything. So, we did that, and we published that in February, so we were able to put into the public arena. There's 70% — roughly 70% of people right now needing oxygen in the world don't get it. That's the access gap. So, when you compare that to the gaps we have for say, HIV/AIDS and TB medicines, it's about 25% of people who need HIV/AIDS meds or malaria meds don't get them. And then the oxygen gap is 70%. So, this is a massive access gap relative to other essential medicines. And oxygen is an essential medicine.
So, we've quantified that, we've costed that. Huge amount of money is now needed to close those gaps. Where will it come from? Certainly, I don't think it's not going to come from global health, which puts the pressure back onto ministries of health and all the development banks, like the Asian Development Bank, African Development Bank, to help them, help the countries finance a proper medical oxygen system.
I'm personally very worried that we'll have another respiratory pandemic soon, sooner rather than later, and the data all suggests it will emerge from Asia again. In fact, the commission put an — I think the commission quoted a 66% likelihood, 66% likelihood of another respiratory pandemic in the next 25 years. Huge risk. So, will we be ready again for the oxygen need, or will we see a repeat of the COVID tragedy? That's the kind of stuff that haunts me. So, the commission was an effort to wake everyone up and say, probably the clock's ticking. We've got to get these systems in place, because we're going to be hit again with another pandemic where everyone is needing huge amounts of oxygen.
Robin Davies: Of course, oxygen is important for so many health conditions, not just pneumonia, but just — yeah, many of the functions of a hospital are reliant on medical oxygen supply. And it sort of strikes me that you have focused a lot of your work on two very neglected areas, oxygen supply, medical oxygen supply and childhood pneumonia, which overlap, but they are distinct. And in both cases, they're sort of characterised by a high degree of complexity. On the pneumonia side, complexity around causes and aggravating factors. And on the oxygen supply side, it's not something that you don't just send oxygen cylinders to people. It's not a commodity supply issue, which is what the Global Fund usually deals with. It involves complex, expensive infrastructure for the production of the commodity. So, yeah, extraordinarily difficult challenges, both of which, in a way, it was good that they were brought to light by the pandemic.
Leith Greenslade: Yeah, yes, it was just a real wake up call. Also, I think sometimes, and this can be an influence of the Gates Foundation, because very technology focused, there's a search for very sophisticated new technologies when sometimes it's your garden variety stuff that's been around for hundreds of years, like medical oxygen, that that's what's needed. So sometimes, I think we were a little bit distracted from the simple, basic stuff. I mean, a lot of the — we did talk to a lot of the global health leaders who were involved in the pandemic response, and we said, why did you neglect oxygen? Why did you miss it? And they just said they didn't realise that health systems didn't have it. Yeah, I don't know what this says about our leadership global health, but yeah, maybe a disconnected or maybe a little disconnected from realities, yeah.
Robin Davies: And often gravitating towards that thing we talked about a little bit earlier in the conversation, the silver bullets, the simple commodities, yeah, the easy, visible things, yeah, yeah. I want to talk a bit about the Asia Pacific region in particular. Now, the problem of childhood pneumonia, as you said, is particularly concentrated in Africa and South Asia. What about Southeast Asia? The Pacific? The numbers will not be as big, but some of the aggravating factors are particularly large, especially pollution, air quality issues in big Southeast Asian cities. What's the scale of the problem in our immediate region?
Leith Greenslade: So Southeast Asia is actually the worst affected region, if you include India, or anything respiratory related for the reasons you just alluded to. I mean, there's a lot of people in the region, for sure, but it's also the pollution, the air pollution, the crowding. And if you look at the forecasts of what's about, what's going to happen if we don't change things, it's just an enormous burden of respiratory infections and chronic conditions, so asthma, COPD, all those things as well that are going to afflict the region. That's India is driving a lot of that. But Indonesia is also, and Philippines, you know, huge, China as well. Big, big burns. I mean this, a lot of this is driven by smoking in China as well.
So, I would argue that although we talk often about Africa, if you're talking respiratory, it's Southeast Asia. And I would include the Pacific in that — I guess South Asia, East Asia and the Pacific in that. This is the area where we really need a lot of action on respiratory across the board. The World Health Assembly last week just passed a resolution called the Integrated Lung Health Resolution. It's the first time I've seen a resolution that put together infectious respiratory like pneumonia, TB is in there as well, as well as chronic respiratory like COPD, asthma and lung cancer is in there as well. So, it bundles all the stuff up that affects respiratory and says we need coordinated action. And certainly, if you look at it through that lens, the hotspot in the world is South — South and East Asia. No question.
I always feel for the Pacific Islands, because during COVID, many of them went into crisis and oxygen shortages. I remember Fiji, particularly Papua New Guinea. Oh, Papua New Guinea suffered. I know the Australian Government did a lot, and a lot of the Australian universities did a lot to try and help the Pacific in that period. So, I know they — and they always — I can remember clinicians from some of the islands saying to me, we can't get anyone to pay any attention to what's going on here. So yeah, I think the need there is great, but I'm quite — with a lot of them did receive oxygen services, and I know that they're working on strengthening those. And in terms of vaccination, there's a wonderful woman at Murdoch Children's Research Institute called Fiona Russell. I don't know if you know Professor Fiona Russell. I’ve got to give a shout out to Fiona. She's done so much for the region in terms of pneumonia, pneumonia vaccination for children. She's a real champion, one of those ex-clinicians who are just real public health dynamos and advocates. Yeah.
Robin Davies: Now you referred to what's happening with global health funding. Well, international development assistance funding in general. In the current circumstances, what do you think is the best strategy for, I guess, protecting the interests of the organisations that we've been talking about and maintaining the strongest possible focus on these neglected issues we've been talking about?
Leith Greenslade: Yeah, so I'm not — I'm not one of those who thinks the sky is falling down. There's a lot of people that are going a little bit hysterical. That's not my view about what's happened. This isn't a major shock to a system that was already unsustainable, and by that, I mean it grew rapidly. And the organisations, I think of them, as the middlemen, the group of organisations that sit between the donor and the groups populations that are in need. And behind the donors are the taxpayers, the taxpayers of Australia, the taxpayers of America, and that's where the money comes from, largely in Europe.
So, we built this enormous system, and this huge layer in between of these massive UN agencies, these massive international NGOs, all of whom take a very large cut of all of that funding. So, it's a system I was critical of that well before what's recently happened, and I could see the inefficiencies, the waste in the system. So, it's been very — and, of course, the dependence that it created, particularly in Africa, and then there's a few Asian countries, but Asia has largely, I think, not fallen into this trap. But a lot of the African nations, you had situations where an entire country health system was funded by the US taxpayer. It's not right from a democratic perspective at all, but we all let that happen.
And of course, the countries when you have a health — I remember, I used to work for Brian Howe, and I remember when Brian used to go into cabinet, and Brian was from the left wing of the Labor Party, so then the right wing dominated. When Brian had to go into cabinet and argue for more money, it was always a fight to get money out of Keating and the rest of them for health, because they had other priorities, and they didn't exactly view health as health spending as an investment. It meant it was just a draw on the budget, so we always had to fight. Now, if Brian had have had an external source of funding, if he could have gone for all that health money externally, they would have just licked their lips and said, you go. You got that covered. And that's what's been happening all across Africa, is finance ministers haven't had to find the money for health because someone external has been covering it, and they've sent their health minister to go hustle for it. And they'll tell you that, the African health ministers will tell you that.
That's why, what's really interesting with the current shock is look at what the Africans are saying. Look at what Kagame in Rwanda is saying. Look at what some of the Kenyan leaders are saying. They're saying it's — we got it. It's okay. They say AIDS has always been a double-edged sword for us. That's the expression Paul Kagame used, and now it's time for us to sort of stand up and get our acts together. They also had a really punishing experience during COVID, and they will never forget it. The African leaders waiting for those vaccines being — you probably remember that, setting up their own mechanism. And finally, the African Vaccine Acquisition Trust.
Robin Davies: So, I think they're looking at it as, okay, it's going to be tough for us, but this is kind of a chance to get our health systems back.
Leith Greenslade: Yeah, yeah. And I guess it's been increasingly unseemly, the competition between the various funds, all in similar lines of business, running replenishments every few years and essentially competing for the same dollars.
Robin Davies: So out of control. The system was out of control. So, do you think it's likely that we will see some, I guess, mergers as a result of the new environment?
Leith Greenslade: Look, I wish, I wish we would have some mergers. But if there's one thing I've learned with the global health architecture, and maybe it's just something about public sector bureaucracies, maybe it's the same for government departments, I'd love your view you on this with your experience. They know how to grow. They don't know how to shrink. They have to be forced to shrink by some external actor, so the donors will have to force them to force a better system. Now, I know the Gates Foundation is thinking about that, exactly about that. How can they use their money to get a more efficient, streamlined international global health architecture?
Robin Davies: I mean, this is your interview, but that sort of would have been the core of my answer. It depends a lot on the Gates Foundation, doesn't it? Because they are such a big player. They were such a big player in establishing all of these separate funds for different purposes, and are such a big player now, because, as we've heard, the Gates Foundation is going to accelerate the disbursement of its funding, $200 billion or so, a lot of money, and it'll be concentrated into a couple of decades. So, in one scenario that that just kind of props up the system for a bit longer as it stands. In another scenario, it can be used to, I guess, accelerate reform of the system. So, I assume that you'll be one of the people providing some advice on that.
Leith Greenslade: Well, I hope, I hope so. I give it a lot of thought, and I think they're heading in the right direction. I think they'll be looking much more at investing in African institutions with deep roots, rather than what they did maybe the first time around, which is now a lot of their money went to — a lot of their research money, for example, went to the Harvards of this world and the UC Berkeleys of this. I don't think they'll do that a second time round.
Robin Davies: All right. Now, for my last question, I just — you talked at the beginning about the Sustainable Development Goals, which are coming up to their end point in 2030, given everything that's happened over the last few years, COVID, the current funding squeeze, is it all bad news? Or are there some positive trends that you can point to that even if we don't hit all of the targets, will we have achieved something by 2030 particularly on childhood pneumonia?
Leith Greenslade: Oh yeah, I love the SDGs. I love the idea of the world having a set of goals. I think there's probably too many of them. I think next time, I hope we have, I hope something comes after 2030 and we have another set of goals. I think having given the world a set of goals and trying to mobilise everyone around them is a brilliant idea, and I think we need it. And I've loved the SDGs. I've loved the health SDGs. I think they're the right goals, this child survival. I think if I had to pick one, I would obviously pick the child survival goal, because we are so close to achieving it.
So just a few years back, when I — a few decades ago, we were losing 12 million children every year, 12 million. It's down to five, down to 5 million. So, it's been halved. And to achieve the SDG, we just have to get it down to just, I think it's around 3 million. So, this is achievable, and then we'll keep going, and we will have a world where it's extremely rare everywhere for a child to die before they turn five. That'll be the first time as a species, we've been able to guarantee the survival of most of our children, no matter where they're born. I mean, a huge milestone for the human species — I hope I'm alive to see that, and that will only have been done because of sheer effort. It didn't happen accidentally, like it was the effort of our species to keep the little ones alive.
So, I'm very optimistic about that. I think it can be achieved. And there are other areas where there's been a — there's been a revolution in gender equality, there's been a revolution in education and primary school attendance. So, in many areas, we've really done remarkably well against some really big headwinds. Obviously, we can be knocked out by wars. We can be knocked out by pandemics, but we bounce back. So, I'm confident we can achieve this child survival goal and several others. But the next five years are critical. They really are critical. But I don't think what's happened with the US needs to be the end of the story, the global health story. I don't know. I don't think so. I think people have a real taste of what's possible, a real taste of what's possible when we can align all these different actors around a discrete set of actions. So now I'm very optimistic, very optimistic.
Robin Davies: Well, on that optimistic note, thank you very much for your time, and I hope we'll have an opportunity to speak again in maybe another few years and see how close we are to those targets. Thank you.
Leith Greenslade: Thanks, Robin. It's been great.
Amita Monterola: Devpolicy Talks is the podcast of the Australian National University's Development Policy Centre. Our producers are Robin Davies, Amita Monterola, Jackie Hanafie, and Finn Clark. You can read and subscribe to our daily blogs on aid, international development, and the Pacific at devpolicy.org. Follow us on Facebook, LinkedIn, Instagram, and Twitter. Send feedback or episode ideas to devpolicy@anu.edu.au. Join us again in a fortnight for the next episode of Devpolicy Talks.