Mothers in Pointe Noire know the value of vaccination. The port city, the second largest in the Republic of the Congo, was a tinderbox of cramped living conditions and poor sanitation when polio came calling in October 2010. The virus, a strain that had threaded its way from India to Angola, before creeping north to Congo, blazed its way across the city with ruthless efficiency as vaccination workers raced to snuff it out. The epidemic killed 180 people in Pointe Noire and the wider area of Kouilou, and left hundreds more paralysed.
Polio usually strikes in young children, killing between 5 and 10 per cent of those it paralyses. Pointe Noire’s victims were largely unvaccinated young men, the legacy of decades of bloody war and a failed healthcare system. Together they formed part of a parched underbrush that was ignited by the virus, and fed its path through the city. The case fatality rate was 40 per cent.
“Immunisation has saved millions of lives, often at the cost of just a few dollars a dose”
“The virus is very good at finding victims,” says Sona Bari, spokesperson for the Global Polio Eradication Initiative (GPEI) in Geneva. “Polio can circulate silently for long distances and it can spread very easily. Immunisation is our best defence against it.”
Vaccines are an elegant science. They mimic disease agents to stoke the body’s critical immune response, priming it to attack if it encounters the pathogen again. They are, without question, among the world’s most cost-effective health interventions, all but wiping out some of man’s most feared plagues. From measles to mumps, whooping cough to diphtheria, immunisation has saved millions of lives, often at the cost of just a few dollars a dose.
As recently as 1988, polio was on the march in more than 125 countries, attacking 350,000 people each year. Today, the virus has been beaten back into just three: Afghanistan, Pakistan and Nigeria. Eradication is tantalisingly within reach: in 2012, there were fewer than 225 cases of polio worldwide.
Still, immunisation is a geographic lottery. The world’s poorest nations remain convulsed by diseases that have faded from memory in the West. Vaccines may be a silver bullet but unaided, fragile states such as Afghanistan and Yemen lack the funds to buy them and the medical infrastructure to distribute them. Drug companies, for their part, can’t count on demand from single, cash-strapped nations being large and predictable enough to cover their costs.
Children pay the price of this disparity. Of the 430 people who died of measles each day in 2011, 95 per cent lived in poor countries. Most were under-fives.
“If you go back to 1990, there were 12 million kids dying before their fifth birthday,” says Chris Elias, president of the global development programme at the Bill & Melinda Gates Foundation, the world’s largest private philanthropic organisation. “Right now we’re at 7 million. About 1.5 million of those deaths... are preventable by vaccine.”
Closing the gap
Bridging this gap falls in part to the Gavi Alliance, a group of scientists, state leaders, philanthropic organisations and more, whose goal is to inoculate children in poor countries. The charity provides funding to buy vaccines in nations whose gross national income per capita is $1,550 or less, paired with grants to bolster their often patchy health infrastructure. This is not hands-off aid. Countries are forced to co-finance vaccination drives, even if this means paying as little as $0.20 a dose, a sum that edges up in parallel with their income. There is also pressure to show how and where cash grants are spent, and to stay on top of vaccine monitoring. By the time a country graduates from Gavi funding, it should be able to pick up the cost of the campaigns itself.
“The cost of the vaccines becomes absorbed into the budget over time,” says Dr Seth Berkley, CEO of Gavi. “It can be a matter of political will – will countries choose to put their money into vaccines, versus other things. But they certainly have the capability.”
Gavi can count its progress in lives saved. Since its launch in January 2000 with a $750m grant from the Gates Foundation, the charity has inoculated 370 million children and averted more than 5.5 million future deaths. Of the $4.3bn in aid it has doled out, nearly half has been funnelled into taming diseases in Organisation of Islamic Cooperation (OIC) member states.
“Aid agencies must keep the pressure on”In Yemen, the poor relative of the Arabian peninsular, the payback has been dramatic. The eruptive state has one of the highest rates of under-five mortality in the world, with 77 deaths for every 1,000 live births. In 2011, its inoculation coverage rate for DTP3 – a trio of doses of diphtheria, tetanus and pertussis vaccines meted out to infants, and a standard measure of immunisation – hit 81 per cent. Globally, the coverage rate is 82 per cent.
Pakistan is the most demanding of Gavi’s wards, mopping up nearly $500m in aid. Vast and unstinting effort has driven its vaccination coverage rate from 58 per cent in 1999 to 80 per cent, snapping at the heels of the global average. It was the first South Asian country to roll out the pneumococcal vaccine, helping to protect babies against the fatal bacterial infections that account for almost a fifth of Pakistan’s child deaths. At less than $4 a shot, says Berkley, it’s a sliver of the amount invested regionally in conflict.
“Many of our countries are important in the sense of the OIC, and obviously many have instabilities related to politics and conflict,” says Berkley. “This is an opportunity to invest relatively small amounts of money compared to what’s being spent on war and anti-terrorism, that could really help the development of the country. These are really good investments in trying to stabilise a region which is now somewhat unstable.”
Reshaping the vaccine landscape has meant overhauling the mechanics of funding. Gavi has driven down the cost of jabs by banding poorer countries together, creating collective economic clout. The result is a high-volume, long-term market, bankrolled by major donors - and highly attractive to pharmaceutical firms. To further spur price competition, Gavi has urged drug-makers from emerging nations such as India and China to pitch for tenders, more than doubling the number of players in the vaccine market.
“Years ago, the pharmaceutical industry used to describe the world as the US, Europe, Japan and ROW - rest of world. That wouldn’t happen today,” says Berkley. “Gavi is 60 per cent of the world’s birth cohort. Nobody puts out a vaccine without thinking about this market, and that’s the kind of equity we want.”
Gavi has also experimented with new financing models, to shrink the gap between the rollout of pricey new vaccines in the West, and in developing nations. In one, it promises to bulk-buy doses from drug-makers in exchange for a fixed, low-cost price. The pneumococcal vaccine, for example, goes for up to $128 in the US but is sold to Gavi at just $3.50 a dose. Donors then pitch in cash to subsidise losses during the capacity scale-up.
The charity has also raised $3.7bn by selling bonds on capital markets, front-loading future aid donations pledged by governments. Investors’ cash is used to buy up vaccines, and is then repaid over time using sovereign donors’ aid contributions. Neither model is perfect and Gavi walks a tightrope. If drug prices are too low, it may discourage other suppliers from entering the market. Watertight price and purchase guarantees, meanwhile, could deter innovation. But its approach has collapsed the time lag seen in vaccine introduction.
“With the pneumococcal vaccine, we got it into developing countries within a year of its launch,” says Nina Schwalbe, head of policy and performance at the organisation. “It used to take 10 or 20 years. That’s a real shift in speed.”
On the ground
Vaccines are just one piece of the puzzle. Ferrying them from factory to field requires a vast army of health workers and volunteers, footsoldiers in the war on disease. From Afghanistan to South Sudan, they fan out across villages and slums, going house-to-house with boxes of vaccines vials packed in ice. In rural areas, workers can be pitifully scarce, raising the risk of children in remote communities falling through the net. The gunning down of nine vaccinators in Nigeria in February, just months after the drive-by murders of eight field workers in Pakistan, is a sharp reminder of the dangers threatening those on the front line.
“It’s one of the biggest challenges we face,” says Dr Mahendra Sheth, regional health advisor for Unicef. “We don’t have enough workers in rural areas. In others, it is only socially acceptable to use female workers, which can limit recruitment.”
To fill the gaps, aid agencies must be creative. In India, yellow-vested vaccinators board moving trains to find children without the inky dot on their finger that denotes a recent immunisation. In Pakistan, field staff camp out at highway tollbooths for buses, to intercept kids with migrant families. Health workers in the central African state of Chad seek out vets: when nomads bring their cattle for attention, they vaccinate their children. For groups such as the World Health Organisation (WHO) and Unicef, the work to find these elusive pockets of children is complex and ceaseless.
“There are thousands of communities that don’t exist on any official count,” says Bari. “The virus is better at finding children than we are in these places.”
Aid agencies must keep the pressure on. In areas where fighting or political turmoil have halted inoculation programmes, disease strains can move fast, reversing hard-won gains. War-torn Iraq, whose public health system was once the envy of the Middle East, today has a lower vaccination coverage rate than Yemen.
“It’s not just about vaccinations: the coverage needs to be sustained,” says Sheth. “It’s the ongoing programmes that really make the difference at a national level.”
Operating in remote regions has its own challenges. Vaccines lose their potency in extreme heat and must be kept stable. Their journey from the factory is a hurried pass-the-parcel from one refrigerator to another, until they reach a clinic or cool box. Fridges, however, cost money and require electricity. Both are in short supply in cash-poor nations. Novel alternatives are being piloted, such as solar-powered fridges, alongside vial stickers that change colour when a vaccine is spoiled. The aim is to iron out kinks in the cold chain, says Bari, and avoid any bottlenecks in supply.
“Parents will walk for hours to health centres to get their children vaccinated,” she says. “They will stand in line, in all kinds of weather. They’ll wait all day if they have to, because they understand the power of vaccination.”
Raising the bar
Battling preventable diseases is expensive. Gavi staved off a $3.7bn shortfall in capital in 2011 with a record funding drive, rustling up more than $4bn from the UK, Norway, and other donors and shoring up its programme to 2015. But the global financial crisis and ongoing economic woes in Europe have raised fears of a drop in future aid funding.
“We have to ask where the next generation of donors will come from. This is expensive work… and it’s really difficult work,” says Berkley. “One of the reasons it’s important for us to talk to the Gulf countries is that we’re spending an enormous amount of money trying to serve the children living in OIC countries, but we’ve had very little support from the region. We just haven’t engaged, and I think in a sense that’s our fault, but we’re starting the process now.”
Of Gavi’s $8bn giving portfolio, about $33m was donated by the GCC states.
Cash is also needed to prod drug-makers into creating cheap vaccines specifically for the developing world. In 2010, a jab to tackle meningitis A was brought to market, driven by funding from the Gates Foundation. Africa is hit hardest by the disease, which spreads each year in a fevered sweep across 21 countries known as the “meningitis belt”. More than 800,000 cases were reported in the 15 years to 2010, causing deafness, disability and death. When the MenAfriVac vaccine was rolled out, sold at $0.50 a dose by Indian upstart the Serum Institute, the impact was dramatic.
“In the places where the coverage has been high, there haven’t been any cases of meningitis. None,” says Elias. “It makes the point of how cost-effective vaccines are.”
The task of stamping out preventable diseases is an enormous one. Flushing out the last 20 per cent of children yet to benefit from immunisation requires reliable funding, an armoury of low-cost vaccines and intense political will. There is, says Elias, no time to wait.
“The fifth child is not standing beside the other four. Then it would be easy,” he says. “That fifth child tends to live in a conflict-ridden country, in an urban slum where there are no services, in a place where the government doesn’t know they exist because their birth wasn’t registered. Reaching the last 20 per cent is much harder than reaching the other 80 per cent. So that’s the challenge.”