Yesterday in TCW Paula Jardine described how the World Health Organisation’s original aim to tackle the multiple causes of health inequality and disease – poor sanitation, lack of clean water, poor food supply, malnutrition – was replaced by one overriding goal, that of universal vaccination. Today she tells how two ‘philanthropic’ foundations joined forces to promote this approach through a global programme that would ‘reverse the fortunes of the stagnant vaccine manufacturers’ and how countries came to be persuaded to indiscriminately target 90 per cent coverage rates for all vaccines on their national immunisation schedules.
IN the 1984 Unicef State of the World’s Children report, its director general James Grant talked of how the developing world was lagging 50 years behind the industrialised world in terms of child mortality rates. Explaining how the industrialised world had succeeded in reducing its own child mortality rates, he acknowledged that ‘the mainspring of this great leap forward was rising living standards – better food, water, housing, sanitation, education and income’.
Although the spread of maternal and child health care undoubtedly played an important role, health technology and medical services played only a secondary part, and the report stated that effective vaccines for measles became available only ‘after child deaths from measles had been reduced to almost zero by better nutrition’.
Yet despite malnutrition being the spectre that loomed large in the Unicef reports, Grant was quick to explain vaccines could help with that as well: ‘All infections are nutritional setbacks. Often the climb back to normal weight and growth takes several weeks. Immunisation against the six main infectious diseases of childhood would therefore be a partial “immunisation” against malnutrition itself.’
It was not long after the retirement of Dr Halfdan Mahler, WHO’s director general from 1973-1988, that Unicef, the Rockefeller Foundation (RF) and other ‘partners’ launched the Children’s Vaccine Initiative (CVI) to encourage developing countries to self-finance their Child Survival Revolution vaccination programmes. This was a significant change of direction. No longer would vaccines be interim aid schemes: they were to be elevated to a strategic priority and meagre health budgets would be redirected to pay for them. The justification made was that ‘that the development, introduction, and widespread use of vaccines in industrialised and developing countries have resulted in considerable progress against some of the most devastating infections of humankind.’
Today, the US Centers for Disease Control (CDC), contrary to the admission in the 1984 Unicef report that vaccines had only a secondary impact on child mortality, claims that the improved socio-economic conditions in industrialised countries only had an indirect impact on disease.
It is more than 20 years since the RF and the Bill and Melinda Gates Foundation (BMGF) joined forces, using the World Bank to create the Global Alliance for Vaccines and Immunization (GAVI), now known as GAVI, The Vaccine Alliance. In the mid-1990s, with new leaders at the helm of both Unicef and the WHO, Dr Seth Berkley, the RF’s associate director of health sciences, proposed to James Wolfensohn, the Rockefeller Foundation trustee appointed to the Presidency of the World Bank (WB) in 1995, that the WB and the RF stage ‘a coup’.
Berkley wanted to replace the CVI, which was failing to live up to the expectations of the vaccine manufacturers: ‘We will have an outside body that can bring in industry [which the World Health Organisation cannot legally do], do advocacy and build a truly international alliance’.
GAVI was officially created ‘to save children’s lives and protect people’s health through the widespread use of safe vaccines, with a particular focus on the needs of developing countries’. Structured as a public-private partnership, largely funded by BMGF and vaccine manufacturers, GAVI’s purpose was reverse the stagnation of the vaccine market, shaping it so more new and underused vaccines could be sold to the developing world.
Until 2017, the WHO modelled vaccine impact estimates for GAVI. However as Gavi’s questions became more strategy and policy-oriented, with a need ‘to better account for uncertainty’ and to be able ‘to estimate the vaccine impact more accurately striving for the highest level of scientific rigour’, GAVI and the Gates Foundation outsourced this modelling work to a consortium led by Professor Neil Ferguson.
The unique selling point of vaccines is that, as products targeted at healthy people, virtually every person on the planet becomes a potential customer and, even better, a repeat customer. Vaccines represent opportunities for continuous growth and profit, unrivalled in the pharmaceutical sector even before Covid-19.
In 2011 when Seth Berkley left the RF to become GAVI’s CEO to oversee the implementation of its ‘Decade of the Vaccine’, vaccines accounted for only 3 per cent of all pharmaceutical sales. But they stood apart from all other pharmaceuticals in one significant way: their sales were growing at twice the rate of any other pharmaceutical product, at 10-15 per cent per annum compared with 5-7 per cent for other products.
A 2013 survey of industry trends prepared by WHO health economist Miloud Kaddar predicted that the global market for vaccines would become an engine of growth for the industry, increasing in market value to $100billion by 2025. In a single year the Covid-19 vaccines alone have eclipsed those projections, generating $150billion revenue for the financial year 2021-2022 according to the World Economic Forum (WEF).
The revenue growth that Kaddar’s survey found didn’t, however, come from developing countries. It came from persuading all countries, whether industrialised or developing, to target 90 per cent coverage rates for all vaccines on their national immunisation schedules. When he conducted his survey Kaddar found 82 per cent of all sales were in fact to the 15 per cent of the global population living in industrialised countries where living standards are highest and where well-nourished populations have the lowest disease burden. The portion of the world GAVI was meant to be targeting remained a largely untapped market.
GAVI’s first task was to increase surveillance of vaccination coverage, which is the number of people in a population who have been inoculated with specific vaccines as recommended in the immunisation schedules. In 2004, for example, in an effort to hit coverage targets, the UK introduced financial incentives to encourage GP practices to increase vaccination rates for three childhood vaccines and seasonal influenza for four at-risk groups.
Additional financial incentives were offered to NHS Hospital Trusts in 2016 to increase influenza vaccine uptake by frontline staff. Unlike the threatened Covid vaccine mandate, flu vaccination is not compulsory but strongly encouraged as evidenced by NHS England’s suggested incentives: ‘Staff appreciate recognition for their contributions to the health of others and including an incentive or reward aspect to a staff flu vaccination programme can be effective. A small treat can have a big impact. Even something as simple as a sticker to show they have had their jab can be worn as a sign of pride and signal to others that they should have the flu vaccination.’
It heralded the bribery and coercion to come with the Government’s determination to achieve population level Covid vaccine take up.
In the third part of this report tomorrow, Paula Jardine examines the concomitant development of IIS or immunisation information systems.