by David Isaacs
It was not until Bill and Melinda Gates started GAVI, the Global Alliance for Vaccines and Immunization, that global immunisation got back on track. That was the year 2000, and it heralded the start of a hopeful new millennium.
Philanthropy and immunisation
Having children made us look differently at all these things that we take for granted, like taking your child to get a vaccine against measles or polio.
Melinda Gates, philanthropist (born 1964)
Americans have a long record – of which they are justifiably proud – of improving access to vaccines through philanthropy. One early example was the March of Dimes (discussed in Chapter 4), the not-for-profit organisation started in 1938 by President Franklin D Roosevelt (FDR) to combat polio. Polio vaccines were not developed with resource-poor countries in mind, but there is no doubt that the March of Dimes has contributed significantly to the global near-eradication of polio.
While the March of Dimes subsequently shifted its emphasis to birth defects and to improving infant mortality, the organisation funded a rubella immunisation program in the 1970s to prevent congenital rubella syndrome, and as recently as 2010 promoted adult pertussis immunisation to protect infants against whooping cough. The primary focus of the March of Dimes has been to improve the health of all people in the United States, rich and poor alike, but the benefits for children in poor countries have been enormous.
The charity Rotary has also played a major role in improving immunisation rates, initially for polio vaccine, but subsequently for other vaccines as well. The first ever Rotary Club meeting was held in downtown Chicago in 1905, when a lawyer, Paul Harris, met with three business acquaintances, a coal merchant, a tailor and an engineer. Their aim was to create a network of businessmen to foster ethical behaviour and good works. They kept on meeting regularly, and called themselves Rotary because they rotated the meetings from one person’s office to another.
Rotary Clubs sprang up in the United States and beyond. In 1922, the organisation became known as Rotary International. By 1925 there were 200 clubs and over 20,000 members.
Clem (later Sir Clem) Renouf was born in the small North Queensland sugar-cane town of Ingham and became an accountant. He was keen to contribute to society beyond the sugar plantations of Queensland. In 1950 a Rotary Club was started in the neighbouring town of Nambour and a friend invited Renouf along. He joined and eventually rose through the ranks to be elected President of Rotary International in 1978.
As his year-long term neared its end, Renouf heard the wonderful news of the global eradication of smallpox, and wondered if Rotary could lead the next great eradication campaign. He rang Dr John Sever, Head of Infectious Diseases at the prestigious National Institutes of Health in Washington DC and a Rotary district officer. Sever rang back two days later to say that polio was maiming over a thousand children a day in the world. Eradicating polio should be Rotary’s target.
In 1979 Rotary went into partnership with the Philippines to improve their rates of polio immunisation. In 1985 Rotary launched PolioPlus, a global program with the aim of eradicating polio. The program was possible because workers with almost no training could drip oral polio vaccine into children’s mouths. From 1995, Rotary and the Indian Government joined in a prototype partnership between an altruistic charity and a national government to achieve the almost unthinkable: India is now free of polio.
Rotary didn’t rest on its laurels in India. The WHO’s EPI had recommended that all children in developing countries receive vaccines against seven diseases – diphtheria, tetanus, pertussis, polio, tuberculosis, measles and hepatitis B – but India was struggling to achieve this. In 2009, only 61% of Indian children were immunised against all seven diseases, and only 65% in 2013.
In 2014, on Christmas Day, also known as Good Governance Day in India, the Indian Health Minister launched Mission Indradhanush. Indradhanush means rainbow in Hindi, and the seven colours of the rainbow represent seven diseases – the six EPI infections plus hepatitis B. Rotary and the Indian Government are again collaborating to try to get these EPI vaccines to India’s poorest children, and have set an ambitious target of 100% coverage by the year 2020. If they can get anywhere near that, they will have saved many thousands of lives.
Another contemporary example of United States philanthropy directed specifically at poor countries is the Bill and Melinda Gates Foundation. Bill Gates co-founded Microsoft in 1975 and made a massive fortune from the computer industry, becoming one of the richest men in the world. There have been many billionaires in the world who have done great good with their fortunes. John and Laura Rockefeller’s foundation promotes education. Solomon and Peggy Guggenheim’s foundation promotes the arts. But I cannot think of anyone besides Bill Gates who has so successfully devoted his money, mind and soul to combating the effects of poverty in developing countries.
Many credit Melinda Gates with being the driving force behind the charitable distribution of Gates’s fortune and the establishment and administration of the foundation. Yet researchers close to the couple say Bill is equally committed to using his fortune to save as many lives as possible. However the credit is attributed, the Gateses make an extraordinary couple and both deserve the highest praise for their efforts to overcome global health inequity.
The Bill and Melinda Gates Foundation was launched with millennial fervour in January 2000, and in the 15 years to the end of 2014 contributed US$44.3 billion to improving the health of children in developing countries. Bill and Melinda are brilliant at seeking and taking advice on the best way to direct their funds in order to have the maximum impact on improving the health of people in poor countries.
Inspired by the Gateses’ example, another United States billionaire, businessman Warren Buffett, has given away 99% of his fortune, most of it to the Bill and Melinda Gates Foundation.
One of the major aims of the foundation has been to improve global immunisation rates, and to this end, also in January 2000, it launched GAVI, the Global Alliance for Vaccines and Immunization (now just called Gavi, the Vaccine Alliance). Gavi is an innovative partnership between the public and private sectors, designed to reduce inequities in vaccine delivery and development. It aims at sustainability by co-funding immunisation programs and using the demonstrated benefits to convince governments to continue funding the programs when Gavi withdraws.
Gavi also negotiates competitive prices with vaccine companies by offering to buy vaccines in enormous quantities if the companies reduce their price. For example, in 2013 Gavi was able to make HPV vaccine, which costs over US$100 a dose in some industrialised countries, available for US$4.50 a dose in developing countries that could afford that price. By the end of 2016, HPV vaccine had been introduced in 74 countries.
This is a win-win situation. The vaccine company does not lose money even though the price is much lower, while the people in developing countries also benefit. If the vaccine company can sell the same vaccine at a far higher price to industrialised countries and make a sizeable profit, which allows it to be ‘altruistic’, then industrialised countries can feel that they too have played a role in making the vaccine available to the poor.
Hepatitis B vaccine cost more than US$70 a dose when first manufactured in the 1980s, and still costs around $25 a dose in industrialised countries, even more in the private sector. But it is sometimes sold wholesale for less than $1 a dose (sometimes as low as 58 cents a dose) to developing countries in Asia with a very high incidence of hepatitis B infection. By the end of 2016, 186 countries had introduced routine hepatitis B vaccine for infants. The WHO estimates that 84% of infants in the world received three doses of hepatitis B vaccine in 2016, and as many as 92% in the Western Pacific.
Gavi has also made a major contribution to improving measles vaccine availability in developing countries, and estimates that 5.5 billion doses have been given since the year 2000. It is truly ironic that in 2016, as European countries struggled with falling measles immunisation rates due to vaccine c
ontroversies, the WHO announced that the global number of measles deaths had fallen below 100,000 in a year for the first time in history. This compares with 2.6 million deaths a year in the 1980s. It is a perfect illustration of how some industrialised countries have become fixated with viewing vaccines from a political perspective, while developing countries can see that those same vaccines will save their children’s lives.
By 2015, Gavi had immunised 500 million children, and 7 million deaths had been prevented. It aims to immunise an additional 300 million children by 2020, which will prevent a further 5 to 6 million deaths. The WHO’s latest target of 90% coverage with all recommended childhood vaccines by 2020 – much more realistic than its original target of 100% coverage by 1990 – is achievable.
What a remarkable legacy for the estimable Bill and Melinda Gates (and those like Warren Buffett who have been inspired by their example). Few if any rich people will ever make better use of their fortunes.
Foreign aid
A cynical view says that wealthy countries give foreign aid to poor countries to gain an economic and political foothold in places that are rich in natural resources and of strategic significance. But when David Cameron became British Prime Minister in 2010, his government took a strong stand against that attitude. Andrew Mitchell, his International Development Secretary, famously declared: ‘We will not balance the books on the backs of the world’s poorest people. Britain will keep its promise to them.’ Even as Cameron’s Conservative government was making cuts to domestic spending, he said they would ‘ringfence’ the foreign aid budget.
Shoring up his position on this in The Observer on 12 June 2011, David Cameron wrote:
Tabitha Mukhali is 32 years old. She lives in Kibera, a slum in Nairobi, Kenya. Last year her eldest son, John, contracted pneumonia. For a month he lay in agony, battling the disease; no one could help him. It was a fight ultimately that he did not win. He was just a year old. But now there’s new hope for mothers like Tabitha. In January this year a new pneumococcal vaccine was introduced to Kenya.
Cameron went on to describe how some of the cost of the vaccine and of training staff to administer it was being funded by British taxpayers. Perhaps Britons felt they had obligations to Kenya, which was once a British colony, but Cameron argued there was also a hard-headed economic reason for giving foreign aid. If wealthy countries had put a fraction of current military spending into helping Afghanistan develop 20 years earlier, much conflict might have been averted. But he asserted that the main reason for giving foreign aid was a strong belief in global equity; maintaining foreign aid was simply the right thing to do. Despite pressure to cut the foreign aid budget, at the time of writing in 2018 Theresa May’s UK Government has honoured David Cameron’s 2015 legislative commitment to contribute 0.7% of national income to overseas aid, a target set by the WHO. Sadly in 2018 Australia’s foreign aid was cut to an all-time low of 0.23% of gross national income. The US has spent less than 0.2% annually since 2015. In contrast in 2015, Sweden (1.4%), Norway (1.05%) Luxembourg (0.93%), Denmark (0.85%) and the Netherlands (0.76%) were the five most generous nations, followed by the UK.
In these days when rich governments like Australia and the United States worry about domestic spending and continually reduce foreign aid, one can only wish they would remember those ringing words of David Cameron and refuse to balance their books on the backs of the poor.
Vaccines for the poor
Existing vaccines target diseases that affect children all over the globe. However, some infections are largely confined to developing countries.
One group of infections that falls into this category is mosquito-borne diseases, such as malaria (caused by malarial parasites) and dengue fever (caused by dengue viruses). The mosquitoes that carry these organisms do not survive in temperate climates, so the infections are virtually confined to developing countries in the tropics. The lack of effective vaccines against these organisms may be caused by the fact that it is too difficult to make them, or the fact that not enough money and effort are being put into doing so.
In 2010, Paul Wilson, a scientist and economist from Columbia University working on global health policy, prepared a report for Oxfam on vaccine access for developing countries. He wrote:
Vaccine research and development is dominated by the paradigm of multinational pharmaceutical/vaccine companies charging high prices for products tailored to wealthy markets. Companies argue that high prices are needed to recoup research and development costs. This model distorts research and development priorities such that companies are not necessarily developing products to tackle the greatest global medical needs and are not producing products that are adapted to the particular needs of developing countries.
One vaccine whose development was delayed for many years because of a lack of will and the improbability of a return on investment was meningococcal A vaccine. The meningococcal A bacterium has a polysaccharide (sugar) outer coating similar to meningococcal C. A vaccine against meningococcal C was developed during the 1990s and introduced routinely in the United Kingdom in 1999. The vaccine is over 90% effective and has since been introduced in many other countries.
It would have been relatively easy to develop a similar vaccine for meningococcal A infection, but this infection occurs almost exclusively in poor African countries. With no financial incentive, no vaccine company was willing to develop a vaccine. Yet the devastation wreaked by meningococcal A infection dwarfed any of the problems caused by meningococcal C infection. Every 7 to 14 years, deadly epidemics of meningococcal A infection sweep across 26 countries in the so-called ‘meningitis belt’ of sub-Saharan Africa, from Senegal to Somalia. Thousands of children and young adults develop meningitis or bloodstream infection as a result. The worst recorded epidemic in 1997 infected an estimated 250,000 people and killed 25,000 children and young adults.
The WHO came up with a novel solution. It developed a partnership with an international not-for-profit health organisation called PATH (previously the Program for Appropriate Technology in Health) to make a meningococcal A vaccine. In 2001, the WHO set up the Meningitis Vaccine Project, which was funded for 10 years with a US$70 million grant from the Bill and Melinda Gates Foundation. The vaccine MenAfriVac was developed within a few years at a fraction of the usual cost by a Dutch biotech company, SynCo Bio Partners, in collaboration with the Center for Biologics Evaluation and Research at the United States Food and Drug Administration. Manufacture was then transferred to the Serum Institute of India. The vaccine was licensed in India in 2009 and became available for use in Africa in 2010. The final price was a remarkably low 50 cents a dose.
Vaccination campaigns were introduced from 2010 in the African countries at highest risk: Niger, Mali and Burkina Faso. In 2011, about 1.8 million people aged 1 to 29 years in Chad were immunised with a single dose of MenAfriVac during a 10day vaccination campaign. Subsequently, the vaccine successfully prevented infection in those who had received it, while infections continued unabated in unvaccinated people.
Gavi has bought 235 million doses of the vaccine to date. It has been found to be 94% effective. In 2015, there were no cases of meningococcal A infection reported in the 16 countries that used MenAfriVac in mass vaccination campaigns. By the end of 2016, six years after its introduction, over 260 million people in Africa had been vaccinated with MenAfriVac. Ghana and Sudan included MenAfriVac in their routine immunisation schedule in 2016, the first two countries to do so.
MenAfriVac is the first ever vaccine developed specifically for the poor. It gives hope that in the future we will continue to find innovative ways to reduce inequities in health.
Reaching the needy
In 1974, when the WHO launched its Expanded Programme on Immunization, fewer than 5 million of the world’s 100 million children were fully vaccinated against diphtheria, tetanus and pertussis. By 1990, just over a quarter of a century later, 76% of the children in the world had received the requisite three doses of DTP vaccine and 73% had re
ceived measles vaccine.
In 2016, the proportion of the world’s 116.5 million children immunised with three doses of DTP had reached 86%. That year, 85% of the world’s children received at least one dose of measles vaccine and the same proportion, 85%, received three doses of polio vaccine. The good news is that polio has been eliminated from almost all countries, and that the number of children immunised against some of the most vaccine-preventable diseases has risen from below 5 million to 100 million in less than half a century. That is formidable progress.
The bad news is that in the same year, 2016, almost 20 million children in the world did not receive routine immunisations such as DTP vaccine. Over half of these children (60%) live in just 10 countries: Angola, Brazil, Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan and South Africa. Some children miss out on immunisations because of war, some because of poverty and isolation.
We humans somehow worked out how to eradicate smallpox. We have almost eradicated polio. Surely it is not beyond our wit to find ways to get vaccines to those children who currently do not get them. To do so, and to sustain it, we will need to persuade developing countries that immunisations are essential for their population’s health, and thus they must devote adequate resources to buying and delivering vaccines. The poorest developing countries that truly cannot afford it will need global organisations like the WHO and the United Nations and philanthropic organisations like the Bill and Melinda Gates Foundation to help out.
Former South African president Nelson Mandela memorably said: ‘There can be no keener revelation of a society’s soul than the way in which it treats its children.’ We are talking about children, the world’s capital.
CHAPTER 15
Immunisation into the future
The English satirical comedy team Monty Python once made a skit about a children’s television program called ‘How to Rid the World of All Known Diseases’. In the skit, one of the presenters, Jackie, breathlessly suggests the answer is to become a doctor, find a marvellous cure for something, tell the medical profession what to do and make sure they get everything right ‘so there’ll never be any diseases ever again’. Jolly good show.