Defeating the Ministers of Death

by David Isaacs

  A second example of ‘altruistic immunisation’ is giving human papillomavirus (HPV) vaccine to boys. The vaccine protects them against penile warts, and may protect them against anal cancer, which affects mainly men who have sex with men, and against penile cancer, which is exceedingly rare. HPV vaccines may also protect against some oropharyngeal cancers (cancers of the throat tissues), although this remains contentious and unproven. But the main rationale is to help protect girls against cervical cancer.

  As with rubella vaccine, boys and society derive benefit if women avoid cervical cancer, but a degree of altruism is involved in immunising boys against an infection for a mostly secondary benefit. There is a difference with the rubella situation, in that we give MMR vaccine at one to four years of age when children’s consent is not sought, whereas we usually give HPV vaccine to 12- or 13-year-old boys, who might reasonably be involved in the consent process. The high uptake among Australian boys suggests they are willing to receive an injection to protect girls, so maybe altruism is alive and kicking.

  What about immunisation for healthcare workers? It seems reasonable to expect them to be vaccinated in order to protect their patients from catching an infection. Most healthcare workers agree, but the evidence that it actually protects patients is poor – even in the case of cancer patients with greatly weakened immune systems. However, there is certainly an argument for making it a condition of employment that staff working with immunocompromised patients be immunised against the most transmissible organisms – influenza, hepatitis B, whooping cough, measles and chickenpox – at the very least. Unimmunised staff could be compulsorily redeployed to other areas.

  In 2013, an Indiana hospital sacked eight employees, including three experienced nurses, for refusing influenza immunisation, which the hospital had made mandatory for all employees. Ethel Hoover, aged 61, wore all black on her last day of work as an intensive care nurse, saying she was in mourning because she had been at the hospital almost 22 years and had only been off sick four or five days in her whole career. ‘This is my body. I have a right to refuse the flu vaccine,’ she said. Her hospital had sacked her rather than let her move to a less critical area, which might have been a fair compromise.

  Is the patient’s right to be protected more important than the healthcare worker’s autonomy? The argument against mandatory immunisation of healthcare workers, much like the argument against compulsory routine childhood immunisations, is that it is preferable to persuade than to punish. Compulsion would hold more weight if there were stronger evidence that immunising staff actually protects patients, but the reality is that most patients get infected by family and friends, not staff.

  One of the main reasons some healthcare workers do not get their annual influenza immunisation is lack of opportunity. We are all short of time, and we all hate paying for things. If vaccines are free and easily available in the workplace, most staff get themselves immunised.

  Immunisation and compensation

  Societies that expect parents to immunise their child to protect that child and to protect other members of society arguably have a moral obligation to provide compensation in the rare event that the child suffers a serious adverse effect. Suppose a child who received OPV were to be the unlucky 1 out of 2.5 million children given OPV who is paralysed by the vaccine? What do we owe the child and family?

  If the country has an efficient public health service, it could be argued that the paralysed child will be cared for by the free health system. Yet the health system cannot compensate for the emotional cost to the child and the family or the lost life opportunities, let alone all the additional financial expenses incurred.

  In 1986, the United States Congress decided on an innovative solution to protect vaccine manufacturers against litigation: they introduced a National Vaccine Injury Compensation Program. It was an attempt to deal with the worrying trend of increasing numbers of opportunistic lawsuits against vaccine manufacturers, which they feared would impair the development of new vaccines. Under this program, manufacturers of vaccines pay a tax to the United States Treasury of 75 cents on each dose of vaccine. If someone thinks a vaccine covered by the program (which includes all routine childhood immunisations and some adult ones) has damaged them or their child, they cannot sue a vaccine manufacturer without first filing a claim with the United States Court of Federal Claims. A determination is made by the court as to whether or not the claim is valid. The claimant can only sue the vaccine company if the claim is rejected or if the claimant rejects any compensation offered.

  In 1961, Germany introduced a no-fault compensation scheme for injuries thought likely to be related to immunisation. By 2005, 18 other countries had introduced similar schemes. The benefits provided include medical costs, disability pensions and compensation for emotional harms. Most of the schemes are conducted under the aegis of State or national governments, except in Finland and Sweden, where they are coordinated by pharmaceutical manufacturers. Decisions on which possible vaccine-related injuries should be compensated are made using pre-established criteria or are assessed on a case-by-case basis, but the standard of proof is usually lower than for court cases.

  Australia has no such vaccine injury compensation scheme, although many public health advocates and ethicists believe it should. I am one of those who has tried unsuccessfully for years to persuade the Australian Government to set up a compensation scheme as the ethical thing to do. The government has put it in the too-hard basket. They now say the new National Disability Insurance Scheme (NDIS) will provide support for anyone with likely vaccine-related injury, but we are yet to see if the support will be adequate.

  Social trust

  Having trusted sources of information – usually the family doctor – helps parents make informed decisions about whether immunisation is safe for their children. However, there is an important interplay between this interpersonal trust and the concept of social trust. The latter refers to trust in collective institutions, including the government and public health bodies, and is influenced by the mainstream and social media.

  Governments and health professionals need to earn that trust and maintain it by ensuring that vaccines and immunisation programs are as safe and effective as possible. This places an obligation on them to monitor the safety of new vaccines, and to be open and honest with the public about any problems that emerge.

  There is overwhelming evidence that immunisation is a potent cause of falling levels of infectious diseases, and that vaccines have never been safer. If the public remains assured of these things, social trust will be maintained and immunisation levels will remain high. High immunisation levels obtained through trust will obviate the need for harsh interventions to ensure children are immunised. This in turn will mean parents feel the government trusts their ability to make wise decisions for their children.

  CHAPTER 14

  Overcoming the iniquity of poverty

  In 2017, a boy in East Timor with advanced cancer presented to a paediatrician working for a charity. In the paediatrician’s homeland, the boy would have received the latest chemotherapy medicines and had a modest chance of survival. But these medicines were not available in East Timor. The paediatrician persuaded the East Timorese Ministry of Health to fund the chemotherapy. A public health physician commented bitterly, ‘There goes my whole immunisation budget for the year.’

  A person born in a Western country today can expect to live 25 years longer than someone born in the same country a century ago. This remarkable change in life expectancy is due to multiple factors, including antibiotics and clean water, but immunisation has certainly contributed significantly. The WHO estimates that 2 to 3 million lives are saved each year due to immunisations.

  However, the WHO also estimates that 1.5 million children under five years old still die each year due to a vaccine-preventable disease; almost all of them live, and die, in developing countries. Parents in first-world countries agonise about the safety of childhood vaccines at the same ti
me as parents in third-world countries are mourning the loss of their child from a vaccine-preventable infection.

  There are two major barriers to immunising children in poor countries. The first is the inability to make better use of existing vaccines, which are not being given because of lack of money or health infrastructure. The second is the lack of availability of vaccines against infections like malaria or dengue fever, which occur almost exclusively in developing countries. This lack of availability is due at least partly to the fact that vaccine companies hesitate to develop vaccines that will not generate profits for them.

  Expanding immunisation to the world

  Donald Ainslie (DA) Henderson led the WHO’s global Intenstive Smallpox Eradication Programme from 1967 and eliminated smallpox from the world within a decade (see Chapter 2). When asked what should be eradicated next, DA usually said, ‘Bad management.’ That caustic comment belied the fact that his contribution to immunisation extended way beyond smallpox.

  While his team was delivering smallpox vaccine in parts of Africa and Asia, DA was struck by the fact that almost no children in those places were receiving the childhood vaccines routinely given to children in his native America and in other Western countries. Surely, he reasoned, something could and should be done about this. In the Bulletin of the World Health Organization he is quoted as saying: ‘We found very quickly that in Africa the average vaccinator could reach 500 African children a day. We wondered “Why aren’t we doing this with more vaccines?”’ It took seven years from 1967 for DA to convince others in the WHO to act.

  In 1974, as I was nearing the end of my medical training and soon to become a real doctor, I did a two-month student elective in a mission hospital in the small town of Moshi in Tanzania, at the foot of Mount Kilimanjaro. There I saw wards of children dying from the complications of measles despite the antibiotics we gave them. Some of them were malnourished, but most of them were a good weight and had previously been healthy. That year, fewer than 5% of children in developing countries received a third dose of DTP and poliomyelitis vaccines in their first year of life, and almost no child received measles vaccine. That year, over a million children died from measles in Africa alone. That year, the widespread use of measles vaccine in the United States, which had started in 1968 and was ramped up in 1973, ensured that only 20 children died from measles throughout the entire country. So much for global equity.

  It was also in 1974 that the WHO finally heeded DA Henderson’s urging and established its Expanded Programme on Immunization (EPI). The EPI’s aim was to radically improve the global uptake of vaccines against six major diseases: diphtheria, tetanus and pertussis (DTP vaccine), polio, measles and tuberculosis.

  This was a laudable aim, but there was a major problem: the program was seriously under-funded. The EPI’s first full-time director, Dr Ralph (Rafe) Henderson – not related to DA – later said it ‘sputtered along with only one full-time medical officer and secretary, supplemented by part-timers lent from other divisions’. Worse, it did not come with any funding for developing countries, so each country had to pay for its own vaccines, and for the healthcare systems needed to deliver the vaccines to children. Progress was difficult due to enormous logistical problems, including extreme poverty, poor health infrastructure, remote populations, poor roads and transport, and failure of the ‘cold chain’ (vaccines can be destroyed if they overheat). War and famine in many countries in Africa and Asia further compromised the already difficult task.

  Dr Halfdan Mahler (1923–2016) was a Danish physician, and WHO Director-General on three separate occasions between 1973 and 1988, and also a pioneer of social justice. In 1977, when the EPI was stagnating, Mahler committed over a million dollars of the WHO’s regular budget to allow the program to employ eight professional and four secretarial staff. He is widely acclaimed for being instrumental in organising the Declaration of Alma-Ata, signed by the WHO, the United Nations Children’s Fund (UNICEF) and 134 nations in 1978. It was one of the most significant moments in public health history. Under the banner ‘Health for All by 2000’, the declaration established health as a fundamental human right. On the 30th anniversary of the Declaration of Alma-Ata in 2008, Mahler said: ‘Unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.’

  In the mid-1970s few developing countries had immunisation programs. Most just responded to outbreaks as they occurred. Ciro de Quadros, who had been so courageous in the elimination of polio from Ethiopia in 1971 (see Chapter 4), was appointed head of EPI in the Americas in 1976. His first step was to persuade individual countries to appoint a national immunisation manager. De Quadros later explained:

  We brought together the country managers and everyone else from the governments working in epidemiology, primary health care, and so on, and listed the problems – how to improve coverage, do surveillance and organise the cold chain – and analysed them. Then we worked on each problem and solution in each country.

  But the big leap forward in immunising the poor children of the world came when the United Nations Children’s Fund became heavily involved.

  The role of UNICEF

  UNICEF had been established by the United Nations after World War II to help children facing famine and infections in war-devastated countries. From 1950, UNICEF broadened its focus to include all developing countries. UNICEF relied heavily on aid contributions from industrialised countries, which provided two-thirds of all its funds. The rest came from private donors.

  In 1954, the movie star Danny Kaye became UNICEF’s Goodwill Ambassador. It was an inspired choice. Danny Kaye was the first celebrity in the world to advocate for a global cause. Instantly recognisable at the time for his gangling dancing, his high-pitched voice and his carefully crafted slapstick comedy, Kaye loved to be with children and was loved by them in turn. He travelled the world for UNICEF, raising awareness and funds, and made a promotional film called Assignment Children about UNICEF’s work in Asia, which was watched by over 100 million people. Describing his work with UNICEF, he later said: ‘I believe deeply that children are more powerful than oil, more beautiful than rivers, more precious than any other natural resource a country can have. I feel that the most rewarding thing I have ever done in my life is to be associated with UNICEF.’

  UNICEF also played an integral role in developing the Declaration of the Rights of the Child, which was adopted by the United Nations in 1959. For this and other work, UNICEF won the 1965 Nobel Peace Prize for ‘the promotion of brotherhood among nations’.

  It was not until 1980, when James P Grant (1922–1995) was appointed as executive director, that UNICEF’s involvement in worldwide vaccination took off. A visionary and a passionate proponent of low-cost, practical solutions, Grant immediately set about making himself one of the most important figures ever in global child health. He gave direction and urgency to UNICEF.

  Grant called the parlous state of the health of the world’s children a ‘global silent emergency’. He focused on three major issues. The first was gastroenteritis, which at the time killed more than 5 million children a year. The solution was just that: oral rehydration solution (ORS), made from adding water to the right quantities of sugar and salt. The second issue was breastfeeding: the WHO and UNICEF’s Baby-Friendly Hospital Initiative was launched in 1991. And the third major focus was immunisation. UNICEF made a major contribution to the EPI by providing specially designed refrigerators and cold boxes to maintain the cold chain. They also provided syringes, needles and sterilisers to aid vaccine delivery.

  Grant believed it was important to measure the successes and sometimes the failures of the initiatives instituted by UNICEF. He initiated a report, first released in 1996, called ‘The State of the World’s Children’, which is still published annually. It documents information not only on immunisation, but also on other diverse topics relating to childhood. Just
before Grant died from cancer aged 72, President Bill Clinton sent him a letter that thanked him ‘from the bottom of my heart for your service to America, to UNICEF and most of all to the children of the world’.

  Under Grant, the WHO set itself an ambitious target of immunising all the world’s children by 1990. Although this goal was unrealistic, it was aspirational. In practice, UNICEF reported that in 1990, 76% of the children in the world received three doses of DTP vaccine and 73% of children received measles vaccine, compared with fewer than 5% of them receiving a full course of DTP or measles vaccine just 16 years earlier in 1974.

  This was a remarkable achievement. However, progress for the next few years after 1990 was slow. The numbers stopped rising at anything like the previous rate, and public health experts began to talk of ‘vaccine fatigue’. I visited Uganda to teach paediatric infectious diseases to young doctors on three occasions between 1990 and 1997, and on each occasion, despite the efforts to introduce immunisation, I saw newborn babies with their faces and limbs rigid with tetanus, and young children dying from severe measles. Health clinics were operating, but HIV infection had hit Uganda and I saw many mothers, infants and older children with AIDS.

  When HIV began to spread, health services in many developing countries had to commit scarce resources to trying to treat and prevent infection, and immunisation services took a lower priority. Parents with AIDS are often too ill to get their children immunised, and children with AIDS do not respond as well to vaccines.