Thursday, March 21, 2013

Vaccines and immunisation: don’t leave a fifth of the world’s children behind

“The hospitals are filled with children with vaccine preventable diseases.”
Johanna Sekennes, Médecins Sans Frontières, Head of Mission, Mali

The rain’s falling thickly onto the roads in rural eastern Mali, preventing cars from passing and making travel by foot virtually impossible. Yet – as a beautifully shot yet hard-hitting new short film, A Preventable Fate, by Venetia Dearden, makes clear – the rainy season does not mean a halt to all industry.  Instead, it coincides with the farming season. Hard-working women, many with children on their backs, labour in the fields to ensure a good crop and a good livelihood. Their responsibilities to the land, to their families and to the sustainability of their agricultural practices, combined with environmental and other external factors, are just some of the complex obstacles standing in the way of them accessing adequate healthcare for themselves and their children. In the first year of their lives, children must receive vaccines five separate times – a tough ask for women given the distance that sometimes needs to be covered, the cost or difficulty of the journey and the other labour-demands a woman is subject to for survival.

The images of rural life in Dearden’s film have a liveliness, community spirit and wholesomeness which belie the tougher realities of under-resourcing in the area and generally in rural and economically disadvantaged regions across the developing world. A Preventable Fate is part of a series of six films around the theme of Fatal Neglect, produced by Doctors Without Borders to highlight the obstacles faced by millions of people worldwide in accessing quality healthcare. The series also includes a study of treatment-resistant TB and three neglected tropical diseases.

In looking at the issue of vaccinations and immunisation in Mali we see that the women working so hard in the fields do not have a day to spare to take their children to be vaccinated – a journey which is difficult even by car, let alone on foot. If a woman happens to live in a village where there is no local vaccine campaign, she may have to go even further away. A Preventable Fate features a woman explaining to a doctor at a vaccine project that she has two children and came to visit the project by bike, “and I got a flat tire. So I had to walk. It’s very difficult.” It is too much to demand of a mother or other caregiver that they take each child to a vaccine campaign outpost at least five times within that child’s first year, when shortages of vaccines may mean that repeat visits are necessary, and that trips are made without knowing whether the vaccines will be available. For those children who receive perhaps two or three of their five shots in the first year, few workable systems are in place to record, trace and make up for the vaccines they have missed when they are a little older.

Photograph (c) Medecins Sans Frontieres

 In addition to the challenges of time, distance and work neglected are problems with establishing vaccination campaigns themselves, in terms of personnel alongside the stocking, transportation, safety and sustainability of medicines. More health professionals who can administer the vaccines are needed; the ideal thing would be to have locally-trained, locally active nurses not just providing vaccines by operating as a reliable and stable way of raising awareness amongst communities. The vaccines must also be transported correctly; a challenge when considering that many require something called a ‘cold chain’, that is refrigeration at a specific temperature otherwise they become invalid. This requires the useage and maintenance of refrigerators and icepacks to store and transport vaccines.

Thus the seemingly simple question of providing vaccines becomes complicated in areas where electricity provision and consequently refrigeration is sporadic, healthcare professionals are scarce, distances between services and users are long, natural temperatures are high and road quality is variable. What is required is the development of vaccines which are easier to deliver and easier to administer to children.

In May 2012 the 65th World Health Assembly designed a Global Vaccines Action Plan to kickstart a well-funded Decade of Vaccines project working towards global vaccination. However, as the Fatal Neglect project makes clear, all major health initiatives must be sensitive to the particular challenges and particular contexts in which healthcare initiatives are established and provided – with a particular focus on those who are being left out due to issues to pricing, the adaptation of medicines and logistical barriers. MSF’s report The Right Shot: Extending the Reach of Affordable and Adapted Vaccines explains some of these issues in detail. They suggest that instead of developing countless (and expensive) new vaccines such as those against pneumococcal disease and rotavirus, the basics of existing routine vaccine systems should be perfected and adapted to theenvironments in which they will be used so that they can benefit the most children, especially in remote, rural, civically fragile/unstable or economically disadvantaged areas. In India’s state of Bihar, for example, 60% of babies are not fully vaccinated. The MSF points out that failure to perfect the access, ease, stability and application of the most basic vaccine programmes have resulted in recent outbreaks of preventable diseases, like the 2010 measles outbreak in 28 African countries. In the Democratic Republic of Congo (DRC) alone, 100,000 cases were reported between January 2011 and October 2011. Although there are many factors affecting the pricing of vaccines, a cynical reading could conclude that the basic, inexpensive vaccines programmes are not being perfected because there is little financial incentive for pharmaceutical companies to tailor their vaccines to help those populations who have little purchasing clout as consumers themselves.

The message on vaccines and immunisations is clear, but tough to swallow. At the moment, 20% of all babies born in the world – that is 22 million children born last year alone - are not receiving protection against basic yet potentially fatal diseases such as measles, meningitis, diphtheria and yellow fever.  Underpinning the moral argument that all children born worldwide deserve the basic human right to life, health, protection and the best start in life, since medicine should not be a luxury is the transformative future effect we can envisage on already-pressurised global healthcare initiatives. Universal vaccination would drastically reduce pressure on hospitals, child mortality rates and sickness rates.  Vaccines must be researched,developed, produced and delivered in such a way that they are easier to use, easier to administer, more temperature-stable, easier to transport, adapted to developing countries’ environmental factors and also the medical factors – that is, the specific strains of the diseases found in the countries in which they will be used. Single dose vaccines which do not required difficult multiple visits; vaccines which are administered orally rather than by injected; well-trained, numerous and either highly mobile or strongly rooted and dedicated local healthcare professionals; vaccines which are affordable to all countries in the long run and not just those which rely on finite donor support through the Global Alliance for Vaccines and Immunisation (GAVI)  to pay for them; and vaccines which do not degrade in variable temperatures would be just some of the ways forward, or more that 22 million children will pay the price.

Photo (c) Medecins San Frontieres




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