More than a cure

‘Fate often takes a hand in these things’, says the eminent Australian immunologist, Sir Gustav Nossal when describing the way he landed on his professional feet after more than 30 years at a Melbourne research institute.

‘My biggest bit of good luck was that my retirement coincided more or less with the time Bill Gates was building up his foundation’, he says.

As chairman of a group of experts advising the US$2 billion Bill and Melinda Gates Child Vaccine Program, Nossal is at the forefront of a renewed campaign to immunise children across the Third World. A major initiative that Nossal says came about through a conversation.

‘One day a person in the WHO Secretariat in Geneva said, “Look, my sister lives in Seattle and I’m going to see her for a holiday, while I’m there is there any point in going to see the Gates Foundation?”’ Struggling to raise funds for immunisation programs within the UN system, Nossal immediately said yes.

Two factors prompted a positive reception with the Microsoft chief and his wife, Melinda, Nossal suggests. The ‘tremendous cost-effectiveness of vaccines’ but also, the couple’s personal circumstances: ‘the fact they had started parenthood late’. But, of course, there is more to this story than fate.

In the early 1990s, many within the global vaccine community were starting to feel that the global immunisation push had stalled. Some countries were suffering ‘donor fatigue’, while others were either unable, or unwilling to lift their immunisation rates.

Moreover, there was a widely held belief that the ‘bottle-neck’ reflected an under-utilisation of those drugs already available.

At the São Paulo meeting of the Children’s Vaccine Initiative (CVI) in 1997, Gus Nossal gave voice to these concerns. Talk of a crisis in the area is no exaggeration. Of the 130 million children born each year, 91 million are born in the developing world, according to WHO figures. One third of these newborns will never be immunised.
 
Two years after Sir Gus Nossal spoke at the São Paulo conference, the Global Alliance for Vaccines and Immunisation (GAVI) was launched. Its objective is to ensure every child in the world is protected against vaccine-preventable diseases, regardless of where they are born. Operating as a financial lever behind the new alliance was the Gates Foundation’s Global Fund for Children’s Vaccines, which was established with an initial grant of US$750 million.

Sir Gus Nossal says this renewed effort is motivated by three objectives. First, to improve the human and physical infrastructure in the developing world, which usually means training health workers giving out the vaccines, but can also include buying new refrigerators to maintain the cold chain.

Second, to increase the delivery of the so-called ‘workhorse vaccines’ that have long been available, but for whatever reason have not managed to penetrate the high Third World death rates from diseases largely eradicated elsewhere.
 
This is no small aim. Five million lives are saved annually from vaccines for preventable diseases such as whooping cough, diphtheria and measles. And yet 40 per cent of African children are still not immunised against measles, despite the disease killing one child across the continent every minute.

Of great importance too, Nossal says, is the acceleration of vaccines that are almost ready to be used—the so-called ‘low-hanging fruit’ vaccines.

Seventy-four of the world’s poorest countries—countries with a GDP per head of less than US$1,000—have been targeted by the scheme. Within four years, it has reached 70 of them. ‘Of the 30 percent of the world that wasn’t immunised with the standard childhood vaccines, about a third have now been immunised’, says Nossal, which equates to ‘an extra eight to ten million kids’.

Under the Gates’ program, a country receives US$20 for every extra child immunised, on the proviso that it will only get access to new vaccines when 80 per cent of the nation’s population is covered.  ‘The carrot was giving money for extra immunisations’, says Nossal while ‘the stick is you can’t get the new vaccines until you get to a reasonable number’.

Reaching diverse populations in the Third World is often fraught with complications. ‘In some situations there have been civil wars’, Nossal says. ‘For example, Nigeria is very unstable and that’s been a problem for us.’

However, Nossal remains convinced that today’s outlook is better than 30 years ago. ‘You have to take progress in small bits’, he says before adding: ‘We haven’t done so well in the prevention of wars, but that’s not really the doctor’s fault’.

Despite this very real progress, Gus Nossal writes that lifting global immunisation rates remains a ‘millennial challenge’ especially in an era of shrinking aid funds and expanding need.

What is needed, he says, is a re-assessment of where health sits on the international aid agenda. In some cases it is also a matter of shifting government attitudes, especially in developing countries where ‘the Health Minister is relatively low in the pecking order’ and overshadowed by an emphasis on economic development.

The irony is that the two are inextricably intertwined. If polio is eradicated by the target date of 2005, there will be an estimated US$1.5 billion saving on immunisation costs alone.

Moreover, the Commission on Macroeconomics and Health, headed by US economist Jeffrey Sachs, has found that the implementation of a US$34 billion health reform program in developing countries would generate a US$186 billion saving.

‘A six-to-one cost benefit ratio, simply because of the better health’, Nossal says. ‘The more capacity kids have to go to school, the less time parents are spending at home looking after their desperately sick child dying of malaria and so on.’ That’s not forgetting the eight million lives saved in the process.

To get an idea of the enormity of the task, consider the longstanding drive to eradicate polio. ‘Five or six countries still have endemic polio’, says Nossal.

‘Whether one is actually going to eradicate it as totally as small-pox is still finely balanced.’ More than three million volunteers are needed to immunise 120 million children on a typical national immunisation day in India. Despite the mass mobilisation programs designed to target those people Nossal calls ‘hard to reach’ (nomads, or the children of itinerant workers), ten million children still miss out.

Nevertheless, most of the world is now polio-free. The Americas recorded their last case in Peru more than a decade ago and Asia in 1997. This is in part because of a WHO–Rotary partnership, Nossal says. ‘Rotary have been absolutely generous, amazingly generous, not only with money, but also with volunteers.’

And yet sub-Saharan Africa and south Asia remain problems, despite renewed efforts to stamp out the deadly disease. Some African nations call ‘Days of Tranquility’, or ceasefires, so that immunisation work can proceed.

Misinformation can also get in the way. Gus Nossal recalls a recent scare campaign in the Uttar Pradesh border region in northern India. ‘The polio deaths had been going down, down, down, then someone started a rumour that the polio vaccine was a plot by the Hindus to give it to all Muslim babies (and kill them).

‘This got enough currency for the vaccination program to be seriously impeded there. All of a sudden in 2002, we had a mini-epidemic, about 2000 cases of polio.’

In response, medical teams entered the territory for a massive ‘mop-up’ campaign. The teams identified cases and re-immunised children and families. The next year, cases fell by a sixth and then the work of immunisation resumed.

‘The aim is to have the last case of polio in the world on the 31st of December, 2005’, Nossal says, ‘but I don’t think we are likely to get there’.

Surprisingly perhaps for the immunologist who has written five books and more than 520 scientific articles in the area, Nossal says improving the health of the world’s poorest populations depends on an understanding that it is ‘not just vaccines’.

‘What about nutrition?’ he asks. ‘We have two to three million children with defective vision because of a lack of vitamin A.’

Ever the optimist, Nossal proposes a simple solution. ‘In some countries it is common to give a dose of vitamin A with the polio vaccine.’ The vaccine has enough vitamin A to last the patient another six months. ‘There has been some progress’, Gus Nossal says. ‘But I’d like to see more.’ 

Madeleine Byrne is a former SBS journalist. She is a fellow at OzProspect, a non-partisan public policy think-tank.

 

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