In global health terms it is hard to find a more striking yardstick with which to measure inequality. Of the 275,000 women who die from the cervical cancer every year more than 85 per cent are in the world’s poorest countries. And yet the vaccine that could prevent 70 per cent of these deaths has not been available partially because of its high cost.
Indeed human papillomavirus (HPV) vaccines, which can cost as much as US$ 130 for each of the three doses needed to provide protection against this deadly form of cancer, have been part of routine immunisation in some wealthy countries since 2007. Meanwhile, women in the countries with the highest burden of disease, where women typically have no access to screening or treatment, and have no access to the vaccine even if they could afford it.
But that is now about to change. Today, we are on the cusp of addressing this gross inequity with a vaccination programme that will mark a transformational moment in women’s health. Thanks to its innovative market shaping strategy and close partnership with pharmaceutical companies, the GAVI Alliance announced this week at the World Economic Forum Africa Summit in Cape Town that it is now able to purchase HPV vaccines at an initial price of just US$ 4.50 a dose with further reductions based upon the volume of demand. This means that starting with demonstration programmes in eight developing countries in the coming months, we will make it possible for more than 30 million of the world’s poorest girls to be vaccinated by 2020.
However, not everyone thinks this is a good idea. HPV is a highly transmissible and common virus and the cause of virtually all forms of cervical cancer. But it is also sexually transmitted and because of this there are certain stigmas associated with it and the vaccine that can protect against it. Some critics say that since the vaccines is not given to infants and instead is provided to girls before they are sexually active – between the ages of nine and 13 – that this effectively gives tacit consent to engage in sexual activity, ultimately leading to increases in promiscuity. Others say that there is little long term data and inadequate surveillance to show that mass HPV vaccinations work.
Consider the evidence though. Certainly it is true that the two HPV vaccines so far approved by the World Health Organization (WHO) only target two of the 15 types of virus known to cause cervical cancer. But it is also true that these two types of the virus, HPV 16 and HPV 18, are by far the most prevalent cancer causing strains. In fact there is even research to suggest that with HPV vaccines there can be some cross-protection, providing immunity against HPV types not targeted by the vaccine.
Convincing evidence is now also emerging of the long-term benefits. Last year the medical journal the Lancet published a study involving more than 18,000 women and girls in Australia which showed a decrease in incidence of precancerous cells in women just three years after a mass vaccination programme, covering all women aged between 12 and 26 years, was introduced.
Similarly, numerous studies have found fears of increases in promiscuity to be unfounded. One recent study involving nearly 1400 girls was published at the end of last year in the journal Pediatrics. It found that after three years there was no difference between the degree to which vaccinated and unvaccinated girls sought pregnancy tests, chlamydia tests or birth control counselling – markers that in rich countries are considered surrogates of sexual activity.
The fact is HPV vaccinations work, which is why since 2009 the WHO has recommended that HPV vaccines be included as part of national immunisation programmes. Moreover this is a view that is clearly shared by the governments of countries that bear the disproportionate burden of cervical cancer deaths. For, since GAVI began accepting applications for HPV vaccine support in 2012 we have received unprecedented demand, with 15 countries applying last year and as many as 20 expected this year.
Most importantly, however, it is recognised by women in these countries, where screening is not an option and where the HPV vaccine is their only hope. They have seen too many women die a painful death from cervical cancer at the prime of their lives. For them, this programme is truly about changing lives, offering millions of women and girls a chance of a healthy future. And where women are empowered, families, communities and nations benefit.
Over the weekend I will be making my way to Botswana to participate in the global thematic consultation on health in the post 2015 development agenda. This meeting brings together civil society, academia, private sector, youth representatives, governments, heads of international health and development agencies as well as members of the UN High Level Panel on the post-2015 development agenda. We will be tasked to consider the input and submissions from people and organisations from all over the world and ultimately make a recommendation to the UN Secretary General on how health should be prioritized in the next chapter of global development.
I would love to hear your thoughts as I prepare to chair a discussion in Botswana on how does health fit in the 2015 development agenda?
We live in a world burdened with increasingly diverse and complex development challenges. As we begin the task of crafting a framework to respond to these challenges, the post-2015 agenda presents an opportunity to rethink what makes development that is inclusive, innovative and applicable to all people. It provides us with a platform to introduce new ways of delivering smart development.
A healthy population is a prerequisite for development. A child, who is borderline nourished, will tip into frank malnutrition if they contract an infectious disease such as measles. Evidence also demonstrates that minimising the burden of illness through health interventions such as immunisation will positively affect a child’s ability to attend school and attain high education levels.
Concurrently, development has a bearing on health. Approximately 25% of the global disease burden is due to modifiable environmental factors. Related effects of unsustainable development, notably outdoor and indoor air pollution are now major causes of global ill health. The greatest burden falls on the poorest population, women and children.
Development is surely about improving people’s lives. A population cannot progress if it is burdened with ill-health. Good health is the foundation on which communities and nations can and do flourish.
Addressing health in isolation of other development challenges such as environment, education and economic growth will diminish our chances of ensuring sustainable change. How can we clearly articulate and support the synergies between health and the other sectors? How can we devise shared solutions to drive people-centred, inclusive development?
What’s your view? Please leave a comment below.
I’m heading to Long Beach, California this weekend for my annual participation in the TED conference – and this year, I’m looking for help, from TED and from you.
To do our work at the GAVI Alliance, we need to make sure that vaccines are not wasted. Vaccines are a powerful technology, but must be looked after very carefully. They have to be stored at a certain temperature and used within a fixed period of time, or they become non-viable. I’m making this the focus of a TED Challenge, asking the smart, innovative people who make up the TED community to help us find a better way to track vaccines. That could involve existing technology like 2D barcodes or RFID tags, or there may be a whole new approach that we haven’t yet thought of. Of course, it requires not just technology, but also appropriate hardware, systems for data transmission, and the ability to scale it up in some of the most difficult places in the world.
I want to make sure we hear all the best ideas, so I’m also asking all of you to help. Are there smart technologies that can help, or better ways to use what we already have?
Click here to read more about the TED Challenge, then post your comments or questions below.
Last week’s announcement of the Minamata Convention on Mercury represents a huge step forward in international efforts to reduce the human health impacts of mercury. For GAVI what is most important about the global and legally-binding treaty is what was left out. The treaty made an exception for thiomersal, a mercury-based preservative that has been used in some vaccine manufacturing since the 1930s to prevent bacterial or fungal contamination of multi-dose vials of vaccine.
The treaty exception represents a triumph of science over the politics of fear. The anti-vaccination lobby pressed hard to have thiomersal – known as thimerosal in the US – included in the treaty despite the scientific evidence that thiomersal poses no human health risk. Indeed, banning it would have disrupted vaccination programs in many developing countries, putting millions of children at risk from vaccine-preventable illness.
The anti-vaccine lobby has been successful in raising fears and doubts about the adverse effects of vaccination and the role of thiomersal in increases in developmental disorders and autism. With parents, scientists and even initially the American Academy of Pediatrics (AAP) weighing in, the United States implemented a precautionary reduction more than a decade ago. There is now a mountain of scientific evidence refuting any link between thiomersal and autism, and AAP reversed their 1999 position that called for elimination of mercury in vaccines. GAVI and AAP share a belief that scientific evidence should guide public policy, and the evidence on thiomersal is clear. It is a safe preservative used in multi-dose vaccines, and at this time there is no replacement for it. Good science and a good global policy.
At GAVI our goal is to reach the world’s poorest children with life-saving vaccines, and while we are pressing for innovations in vaccine delivery systems, the realities of the current cold chain and storage capacities in developing nations make multi-dose vaccines containing thiomersal a necessity. Without it the number of children receiving vaccines in in 120 countries, mostly in the developing world, would plummet. The World Health Organization estimates that thiomersal-containing vaccines avert at least 1.4 million child deaths every year by protecting children from fatal diseases, such as diphtheria, tetanus, and hepatitis B (1). By using multi-dose vaccines, we can reach more children, and we can save more lives.
It is encouraging to see that the treaty negotiators used good science to inform this important global policy. We need to build public confidence in vaccine safety, and reach the 22 million children who currently lack access to vaccines. As a doctor, an epidemiologist and a father, I know that childhood vaccination is a fundamental building block of health, and it gives me confidence to see that the treaty negotiators recognised that as well.
(1) The Lancet, Volume 379, Issue 9834, Page 2328, 23 June 2012
As CEO of the GAVI Alliance, I am coming to Davos to talk about the challenges and opportunities of public-private partnerships, with an emphasis on innovative financing. The World Economic Forum Annual Meeting is the perfect place for a dialogue that brings together industry, civil society, UN agencies and countries around a shared response to the challenge of protecting children against vaccine preventable illness. In 2000, the Forum acted as midwife to the birth of GAVI and since then we have supported collaboration with a singular focus: giving children in developing countries the same protection from vaccines that children in developed countries receive.
In an increasingly complex world, we have a simple and bold vision that all children should have the opportunity to grow up healthy. The Annual Meeting 2013 theme of Dynamic Resilience challenges participants to move beyond simple solutions to strategic collaboration and new methods to create a more just and sustainable future for all.
This week, Forum participants will have the opportunity to consider global challenges, including the Millennium Development Goals. In the past, global goals have tended to be oriented around diseases as a proxy for immunization rates. I believe that the global community should now move to the idea of a “Fully Immunized Child”, which means measuring how many children have received all of the vaccines recommended by the Word Health Organization for global use that they need to keep them safe.
The pathway to a more sustainable future for all children must include access to the basic building blocks of good health, including nutrition, water and immunizations. To achieve this goal, business, governments and civil society will need to work together and find new and innovative ways to deliver vaccines equitably to all children and to measure that delivery. At GAVI, we take measurement seriously. It is the only way that we will ultimately help each country deliver on the goal of equity between and within countries.
Since 2000, in collaboration with our business, government, UN and civil society partners (many of whom are participants at the World Economic Forum), GAVI has helped to prevent more than 5.5 million deaths in the world’s poorest countries, and committed US$ 7.2 billion to new and underused vaccines and to strengthening health systems. We have added new vaccines that target the two largest killers of children – pneumonia and diarrhoea – and are now rolling out our second vaccine against HPV, which causes cervical cancer and kills 275,000 women a year. Yet, we estimate that 22 million children still lack access to vaccines, so we have our work cut out for us.
At Davos, I will be co-hosting a breakfast with Bill Gates to announce funding and partnerships made possible through the GAVI Matching Fund. The Fund is an innovative finance mechanism that matches contributions from companies, foundations, their customers, employees and business partners. The Fund also provides a setting for innovations in collaboration and the delivery of technical expertise to our shared mission of increasing access to vaccines for all children.
I have a passion and a sense of urgency about our mission because I know that vaccines offer an incredible return on investment, and that a vaccine dividend can be measured in lives improved and lives saved.
Last week GAVI convened a group of experts to examine the evidence on the value of vaccines. We knew that vaccines prevent sickness and death. But there’s also great evidence that being vaccinated helps people in many ways throughout their lives – building their health and their resilience. Children who are healthy – and have adequate nutrition – are much more likely to attend school. People who finish school, and do well, have higher earning potential in their adult lives. GAVI’s hope is that these healthy young people will enter the workforce and build the vibrant global economy of the future.
I am optimistic about the future because the evidence is clear about the economic impact of immunization. If parents don’t have to spend money on their children’s healthcare, they can use it for other purposes. If they don’t need to spend the money on health, they can spend or invest the money, which leads to economic growth in local communities and the country more broadly.
Healthy children are resilient children, and immunization is a fundamental building block for health. And the power of vaccines means that we can also target not only acute infectious diseases but also chronic infections that create chronic disease burdens that are so difficult to manage. At GAVI, we are committed to collaboration and partnership – working with business, governments, the UN and civil society to see more and more of the world’s children (and adults) fully immunized, wherever they live.
This blog post also appears on forumblog.org.