Vaccines for all the children: From vision to reality
By Jens Stoltenberg1
Vaccines are a medical miracle. Administered a few drops at a time, they save millions of people every year from crippling and lethal diseases that have afflicted mankind for generations. Norway and other wealthy countries rely on vaccines to keep many diseases in check. We Norwegians should thus feel a strong moral duty to find the extra NOK 1 billion (about $143 million) that is needed to vaccinate the children of the world. The time for political action is now.
If all of the earth’s children are to be immunized, Norway must persuade other countries and private organizations to increase their support for vaccine programmes. Norway must also dig deeper into its own pockets. But my country’s responsibility must not end there. When the pledges from around the world are all tallied, Norway should step forward again and provide whatever amount is still lacking.
In this article I will discuss how the world community can make major progress in the battle against poverty and need. I have been active in promoting vaccines since 2000, first as prime minister of Norway and later as a board member of The Vaccine Fund2. This global fund, chaired by Nelson Mandela, manages money contributed for immunization programmes in countries whose gross domestic product (GDP) is less than $1,000 per inhabitant.
Bad faith to turn away
More children die yearly from measles, whooping cough and other common childhood illnesses than from AIDS, whose primary victims are parents. Yes, the world community must redouble its effort to vanquish AIDS/HIV, but that epidemic’s intractability should not distract us from fighting what should be an easier battle against measles, whooping cough, diphtheria and other childhood diseases. We know what it takes to defeat them. The vaccines are tried and true. There is no excuse for allowing such diseases to kill large numbers of children. The fact that they do is a political and moral scandal of global proportion. Why are they permitted to flourish? There is no easy answer. But the lack of resources in poor countries and a lack of coordination among the many organizations devoted to vaccine distribution are certainly contributing factors.
Nordahl Grieg wrote: Noble is man. Rich is the earth. Where there is hunger or need, there is betrayal. It is a betrayal when millions of children die of diseases they could simply have been inoculated against. Our calling is to put an end to this absurd situation. It is a moral duty. But it is also a profitable investment. Healthy children are important to economic growth, and vaccinating them is one of the surest ways to produce results.
It is well documented that bold health initiatives can help reduce the burden of disease that poor countries bear. There is also general agreement that economic development leads to better national health. Less well known is the fact that fighting disease can significantly advance the cause of economic development.
Economists have long been criticized for underestimating the significance of health in socioeconomic matters like poverty. They are said to view health as a consequence, and not a cause, of economic and social development. Yet in my own field - social economy - I have noticed the experts beginning to take a broader view. In recent years, for example, their attention has extended to the environment and the obligations we must place on business to achieve sustainable development. The fight against poverty, too, is now viewed in a larger economic context. Economists, in my experience, are often the driving force behind innovative new approaches.
The professors David Bloom and David Canning3 have shown that health has a major influence on people’s income and development opportunities4. According to their studies, this influence can be seen first and foremost in productivity. Good health leads to higher productivity, lower absenteeism and heightened job satisfaction. People with good health also live longer and are more interested in developing their skills and educating themselves and their children. The likelihood of living longer inclines people, in turn, to save more for their retirement years. Such saving often means investment, which strengthens the economy. Finally, improved health shows up in a lower mortality rate; this leads to a lower birth rate and better control over population trends - both of which are critical to fighting poverty.
In 2001 the Commission on Macroeconomics and Health, chaired by Professor Jeffrey D. Sachs, submitted a report documenting the catastrophic effects of disease and poor health on people, societies and economies.5 The report’s message was that providing everyone with a bare minimum of health services could save millions of lives, reduce poverty, boost economic development and, in the long run, help bring about a world with less social division and conflict.
One basic health service highlighted by the Sachs commission was the immunization of children against disease. That finding was hardly a surprise. Vaccinating children is one of the most effective of all health measures. When smallpox was finally eradicated in the 1960 and 1970s, the world became a safer place for us all. Soon, vaccines may also eliminate polio. Already its decline has spared mankind untold suffering. I remember well my visit with polio-afflicted children at a clinic in New Delhi in April 2001. Children with leg braces and crutches, leaning on a gate for support, met me at the entrance. The polio virus had disabled them for life. Inside the clinic, however, infants were given two drops of polio vaccine each. They were lucky. Those drops would protect them for the rest of their lives.
In Norway, parents and guardians take their small children to local health stations for routine inoculation to guard against diphtheria, tetanus, whooping cough, polio, German measles, mumps, measles, meningitis (Hib) and tuberculosis. Nearly 100 percent of Norwegian children are vaccinated, and the protection lasts a lifetime. During the 1980s, many poor countries managed to increase the breadth of their vaccine distribution. Then came years of stagnation. Global coverage is now about 75 percent. But in the poorest countries, far fewer than half of the children receive vaccinations.
The consequences are dramatic. At the turn of the millennium, some 30 million children born each year6 were not being vaccinated against the most common childhood diseases. An estimated 3 million of them will eventually die of illnesses that children in wealthy countries need never fear.
But death statistics tell only part of the story. Many children cheat death only to face long-term sickness and suffering. Whole families are affected when parents must cut back on paid work to tend sick children. The history of development makes clear that the first thing needed to reduce birth rates is to reduce child mortality. This was true in Norway, too. Parents tend to have lots of kids when they know from experience that not all of them will grow up. Yet when parents gain the luxury of looking beyond survival, to the world of work, education and development, child mortality and the birth rate invariably go down. Family life becomes more stable. Complications during childbirth remain a major cause of death for women in many countries, with staggering consequences for families. Dad is often left with a large flock of children, the youngest being a newborn. But a declining birth rate stemming from improved overall health among children will mean fewer women dying in childbirth.
A new alliance
Four years ago, an unusual alliance was formed to invest heavily in better health as a way of reversing negative trends in the poverty fight. The Global Alliance for Vaccines and Immunization (GAVI) was established by (and still consists of) United Nations organizations such as WHO and UNICEF as well as the World Bank, the pharmaceutical industry and representatives from both rich and poor countries. The Vaccine Fund, for its part, was set up to harness resources for the type of work that GAVI performs. Many nations have contributed to the fund; so, too, has the Bill & Melinda Gates Foundation. In addition to providing vaccines for children in the world’s poorest countries, the donors are determined to strengthen the health-care systems in those countries. That way, common vaccines are more likely to reach all who need them, and unusual or newly developed vaccines can be introduced systematically as they become available. The Gates foundation alone has given some $750 million (about NOK 5.2 billion) to The Vaccine Fund over a five-year-period - a solid foundation on which to assemble additional support.
The vaccine initiative caught my attention when it was launched with international media fanfare in January 2000. I had long been aware that inoculations were among the most cost-effective measures available to the health sector. I had also noticed, in the professional literature, an increased emphasis on health and education in the fight against poverty. As a political leader I have tried to elevate this perspective in international development policy. If governments do not show what their development budgets are being used for, and what results are being achieved, there is a danger that popular support for such assistance will decline.
From the start, GAVI was an impressive organization. It had the support of important international players. Its preventive-health goals were ambitious, but also realistic; and if achieved, they would have the follow-on effect of reducing poverty and boosting development. That is why early in 2000 I wanted the Norwegian government, which I led, to take a clear stand in support of the vaccine initiative. When we announced our intent to contribute NOK 1 billion (about $143 million) over five years, we found broad support in the Storting, or Norwegian parliament. The appropriation was secured in a budget agreement that we reached with Norway’s centrist parties in the fall of 2000.
The idea is as simple as it is challenging: to distribute life-saving vaccines to clinics and villages around the world. Immunizing a child against life-threatening diseases costs between NOK 150 and NOK 200 ($22 to $29). But assembling the money and the vaccines is not enough. The health systems in recipient countries must be up to the task of administering them widely, often across vast territories. That is why 20 percent of GAVI’s resources are directed toward infrastructure - a portion that is wisely chosen. Too often we have seen that donor programmes focusing exclusively on equipment and materials tend to fail. We have also learned that foreign investment in a country must build upon plans that that country has formulated for itself. The people there know best what type of system will reach the most children. Support from GAVI is contingent, moreover, on a local commitment of budgetary resources. Such commitment increases the likelihood that outside funds will be efficiently coordinated with a view to the long term. GAVI’s innovation in such matters has earned it the respect of its partners. More importantly, global vaccine coverage is expanding steadily, with nearly 70 countries now working hand in hand with GAVI.
Long-term support from GAVI is determined by results. Countries receive an initial investment with which to purchase vaccines the first three years, but continuing assistance is based on the results achieved. Accounting firms such as Price Waterhouse Coopers undertake a thorough examination of the countries receiving support and ascertain that their clinics are administering the vaccines as planned. GAVI’s support to Kenya has levelled off because the country did not meet its agreed-upon goals. Uganda, on the other hand, has received expanded support as a consequence of vaccinating more children than originally foreseen.
GAVI’s efforts are starting to pay off. As a result of its initiative, standard vaccines have reached nearly 8 million children in more than 55 countries. In addition, newly developed vaccines against scourges like hepatitis and meningitis have been made available with shorter lead times. Such relatively unusual vaccines - provided by GAVI and others - have now been administered to more than 30 million children worldwide. At last, the number of vaccinated children in the world is rising and child death statistics are declining. We now estimate that almost half a million lives have been saved as a result of vaccine programmes since 2000.
With fewer children dying and fewer getting sick, the clinics where GAVI’s vaccines are administered have grown in local status. This illustrates how a wise investment can have indirect as well as direct consequences. In Norway, too, we know that when parents bring their children to a clinic for vaccinations they often leave with a great deal more. They receive information on nutrition, preventive health, contraception, children’s health and other useful subjects.
Strengthening health clinics can help poor countries respond effectively to a variety of health-care challenges, including the AIDS/HIV epidemic. I observed how during a visit to a health clinic in Dakar, Senegal, just before Christmas. The process of vaccinating children put health personnel there in direct contact with mothers - a meeting that was ideal for passing on information and a variety of medications. In Ghana, the Red Cross has instituted a project in which mothers who bring their children to be vaccinated are given specially treated mosquito nets that protect against malaria. Malaria takes about a million lives every year, and there is no vaccine against it. But malaria does more than just kill people. In Africa alone, according to the Sachs commission, the sickness has siphoned off $100 billion (about NOK 695 billion) in the past 20 years. Yet we know that if all the children in afflicted areas could just sleep under mosquito nets, the malaria death toll would be halved. Administrating vaccines provides an excellent opportunity to address other health problems.
Renewing the effort
The vision: Vaccines for all the world’s children.
Looking toward the year 2015, it is realistic to imagine a world in which 9 of 10 children in the 75 poorest countries are vaccinated against life-threatening diseases. That degree of success would mean the survival, every year, of as many as 3 million people who otherwise would die for lack of childhood immunization.
Within GAVI and The Vaccine Fund we are discussing whether to open a new phase in the battle against disease. While continuing to expand global vaccine coverage by current means, we would also strengthen the capacity to mount targeted vaccine campaigns when and where disease outbreaks occur. For children, measles epidemics are particularly deadly. Planning is also underway to confront tetanus more aggressively; that disease kills about 700 children and 100 birthing mothers every day. Shortly before the recent earthquake in Bam, Iran, health authorities there had supervised an extensive round of measles vaccinations. Obviously, the catastrophe would have been far worse if accompanied by a measles epidemic. GAVI is also busy supporting research into new vaccines, including compounds that would prevent various forms of diarrhoea and malaria.
I represented Norway when the Millennium Declaration was signed at the United Nations in September 2000. Most of the Millennium Development Goals were formulated there, and most had to do with health. Some goals, it’s clear, will be hard to achieve. Economic growth in big countries like China and India makes the task easier, but the poorest countries are struggling, and some are actually losing ground. Wherever possible we must intensify our efforts.
We can afford it
What will it take to succeed? First, good planning and expanded service capacity in the countries affected. GAVI has developed sound routines in this regard. The main outstanding challenge is money. We need resources, and we need the will to stay the course for as long as necessary. That is were Norway comes in. It is time for us to assume a leadership role while encouraging other prospective donors to join the cause.
We did so in 2000. Thanks to broad political support in Oslo that year, Norway was among the leading donors to the vaccine project. During budget negotiations that fall I was pleased to gain the support of Kjell Magne Bondevik (the Christian Democrat who succeeded me as prime minister) to increase Norway’s annual contribution to NOK 300 million (about $43 million) through 2005. We have now extended Norway’s commitment for a new five-year period, through 2010. Norwegian contributions will thereby total NOK 2.7 billion (about $388 million) for the period 2001 to 2010. We must take care to preserve this consensus. Fortunately, vaccines are a win-win issue across the political spectrum.
The goal is quite concrete - to vaccinate our youngsters against common, life-threatening diseases. We know this will promote development and help reduce poverty. The focus on immunization also signifies a new type of development policy, one in which several parties join hands to reach a common goal, in which results are verifiable, and in which additional funds are incorporated without adding bureaucracy.
Both national governments and international organizations are already investing large amounts of money and energy in vaccination programmes. Agencies like UNICEF and WHO have worked on the issue for many years, as have volunteer organizations the world over. It is crucial that those efforts continue. If distribution programmes are cut back, it won’t help much if GAVI and The Vaccine Fund raise money to buy new vaccines. Officials in The Vaccine Fund are at work on a model to estimate how much additional money will be needed to inoculate all the world’s children - or at least to increase vaccine coverage in poor countries from today’s 70 percent to some 90 percent by 2015. The funding increase necessary to achieve such coverage is about NOK 3 billion (about $430 million) per year, according to preliminary estimates. Commitments already made by governments and private donors account for about NOK 2 billion (about $288 million) of the increased amount. Even assuming all the commitments are honoured, we are still NOK 1 billion (about $143 million) per year short of our goal.
Norway can lead
There is broad political support in Norway for increasing our overall development-aid budget to 1 percent of gross domestic product (GDP). Because Norway’s economy is growing, the development budget actually grows by several hundred million kroner per year even when the percentage share of GDP stands still. But it is not standing still. The share of GDP devoted to development aid actually grew from 0.93 percent to 0.94 percent between 2003 and 2004. The total aid budget thus rose by NOK 603 million (about $87 million), reaching today’s level of NOK 15.3 billion (about $2.2 billion) and is likely to continue growing each year. In other words, the cost of what I now propose is fully within our ability to pay.
I am calling for a bold, cross-party pledge within Norway to foot the bill so that GAVI can reach its full potential as a tool to reduce child mortality and poverty. Today we give NOK 300 million (about $43 million) per year. That is fine. But I think we are able to increase that amount several fold. We must continue providing the amount we have budgeted, and we must persuade others to give more. Whatever shortfall then remains must be Norway’s to fill. Only then will we have done everything in our power to immunize the world’s children against disease.
We can prove that the battle against poverty is not entirely quixotic. Important goals are within our reach. Today, people in need have good reason to hope for better health, and people with resources have good reason to expect their gifts will make a difference. The way forward is simple - almost banal. We know exactly what to do and how much it will cost. Now we must do it.
Poverty must be fought on many fronts, of course. Fair trade, education, infrastructure investment, anti-corruption measures - all will improve the plight of the world’s poor. Many such worthwhile undertakings are demanding and complex, but that is no reason to overlook measures that are easy to implement. On the contrary.
Precisely because poverty is such an intractable adversary, we must, at a minimum, vaccinate the children. Valuable returns on such an investment are assured.
All this was on my mind as I sat in a narrow corridor of that clinic in Dakar, surrounded by Senegalese mothers. They knew they were lucky. Their children were about to receive live-saving vaccines. Two drops in the mouth. A shot in the arm. Protected for life.
It was a medical miracle - one that all children deserve to experience.
1 Jens Stoltenberg (b. 1959) is the leader of Norway’s Labour Party. He is also a member of the board of The Vaccine Fund, which is chaired by Nelson Mandela.
2 Nelson Mandela (chair), Graca Marcel (vice chair), Patty Stonesifer, Jacques-Francois Martin, Jacques Delors, Her Majesty Queen Rania Al-Abdullah of Jordan, Dwight L. Bush, Tore Godal, Charles J. Lyons, Mary Robinson, Mstislav Rostropovich, Amartya Sen, Jens Stoltenberg, Lawrence H. Summers, George W. Wellde
3 Harvard University
4 D.E. B.oom and D. Canning, “The health and wealth of nations,” Science, Vol. 287, 1207, Feb. 2000
5 “Macroeconomics and health: Investing in health for economic development,” Report of the Commission on Macroeconomics and Health, 2001
6 World Health Organization/V&B/03.20
GAVI Progress & Challenges 2004
GAVI fact sheets
OPED piece by Queen Rania of Jordan; Mary Robinson, former President of Ireland; and Jens Stoltenberg, former Prime Minister of Norway (PDF - 12K)
Vaccines for all the children: From vision to reality - by Jens Stoltenberg (PDF - 32K)
15 April 2004: Press Statement by Former South African President Mandela and Graca Machel
27 February 2004: GAVI and The Vaccine Fund Launch New Drive to Save 1 Million Children
15 April 2004: Mandela, Machel meet former Norwegian PM
SABC (South African Broadcast Corporation)
April 2004: Helping Tradition Meet Modernity - Queen Rania one of TIME Magazine's 100 most influential people
Time.com (subscription required)