Global Health Insights from the 2015 Gates Annual Letter

-Written by Adenike Onagoruwa, PhD (Contact: adenike.onagoruwa@gmail.com)

For the seventh consecutive year, Bill and Melinda Gates have released an annual letter, discussing the Gates Foundation’s activities and sharing progress on the fight against poverty and disease. An organization headed by two of the world’s most powerful philanthropists, the Gates Foundation funds global health, development and advocacy efforts aimed at reducing poverty and eradicating preventable diseases that disproportionately affect the developing world population.

Through its grant-making and operational activities; the Foundation has, especially in the past decade, set the health agenda for aid organizations, research institutes and even governments around the world. It is therefore quite important to pay attention to the insights, priorities and goals outlined by these primary players in the global health and development arena. With the upcoming expiration of the Millennium Development Goals (MDGs), this year’s letter evinces the momentousness of 2015.

Released at the start of the year, the 2015 Gates Annual Letter titled “Our Big Bet for the Future” makes ambitious predictions regarding the next 15 years. The big bet is this: “The lives of people in poor countries will improve faster in the next 15 years than at any other time in history. And their lives will improve more than anyone else's.” Acknowledging the absurdity of this bet in the face of seemingly worsening world problems (they do add a caveat that a handful of the worst-off countries will continue to struggle); the two give these reasons why they think there has never been a better time to accelerate progress, resulting in longer lives and better health:

●     “There will be unprecedented opportunities to get an education, eat nutritious food, and benefit from mobile banking.”

●     “These breakthroughs will be driven by innovation in technology — ranging from new vaccines and hardier crops to much cheaper smartphones and tablets — and by innovations that help deliver those things to more people.”

The key global health breakthrough they foresee happening by 2030 is that “Child deaths will go down, and more diseases will be wiped out”. Here’s how:

Cutting the number of children who die before age 5 in half again. The percentage of under-five deaths worldwide has been cut in half (1 in 10 children in 1990 to 1 in 20 today). 1 in 40 children by 2030 can be achieved by

●     scaling proven, existing interventions for saving newborn lives such as: immediate and exclusive breastfeeding for the first six months; delivering injectable antibiotics immediately a baby appears ill; basic training for resuscitating a struggling-to-breathe newborn with a hand-pumped oxygen mask; immediately drying and warming the newborn after delivery through skin-to-skin contact; and topical application of chlorhexidine to the umbilical cord for prevention of sepsis specific mortality.

●     Comprehensive immunization - almost all countries will include vaccines for diarrhea and pneumonia, two of the biggest killers of children, in their programs.

●     Improved hygiene and sanitation to reduce disease spread - through simple hand-washing and innovative toilets specially designed for the poor.

●     Leveraging on the work that has been done to strengthen country-level health systems in many poor countries.

Reducing the number of women who die in childbirth by two thirds. The number of mothers dying will go down by:

●     Increasing the number of women that give birth in healthcare facilities instead of at home.

●     Making sure that caregivers at healthcare facilities are well-supplied and well-trained.

●     Improving access to contraceptives and to information about pregnancy spacing.

Wiping polio and three other diseases off the face of the earth. Polio, elephantiasis, river blindness, and blinding trachoma can be eradicated by 2030 through:

●     Free medicines made possible by continuing donations from pharmaceutical companies.

●     Strategic delivery of these medicines aided by advances in geographic information systems for disease surveillance.

Finding the secret to the destruction of malaria. While the two are not optimistic about the elimination of malaria by 2030, they believe that all the tools for its complete eradication will be available by then. By 2030, based on early versions of these tools currently in development, it is anticipated that:

●     There will be a vaccine that will prevent the transmittal of the malaria parasite from infected persons to the mosquitoes that bite them, thus halting the spread of the disease.

●     There will be a single-dose cure that will completely clear the parasite from infected persons.

●     There will be a diagnostic test that can provide immediate results on infection status.

Forcing HIV to a tipping point. Alongside efforts to develop a vaccine or cure for HIV, HIV will be forced to a tipping point globally when:

●     The number of people beginning anti-retroviral treatment in sub-Saharan Africa surpasses the number of newly infected people.

●     The high HIV transmission rate in sub-Saharan Africa is arrested, leading to a worldwide reduction in HIV cases.                 

Progress towards these health breakthroughs will be complemented by parallel progress in agriculture (innovations to increase yield and improve nutrition content in order to increase earnings and reduce malnutrition); education (the creation of better technology to revolutionize learning, make online education easily accessible and reduce the gender literacy gap); and banking (increased access to mobile banking that gives the poor more control over their finances, makes transactions more efficient, less time consuming and makes it easier to borrow and save).

What does this letter mean to the health and development community? Well, as one of the biggest funders, the letter provides a projection of what we can expect to see in global health programming in the years to come. For instance, there will be an emphasis on scientific and technological discoveries aimed at reducing maternal and child mortality. Organizations working to develop vaccines as well as rapid, low-cost diagnostic tests and medical devices will receive priority funding. Just as the MDGs have been used as a framework for driving actions and policies in development, the goals outlined in the 2015 Gates Letter will certainly have impacts on programs and policies in many developing countries, as well as on the funding directions of other donor agencies.

The master plan of the Gates touches on several vital issues that are central to health and development and is sensitive to the gender applications and implications of proposed activities. It galvanizes public engagement with the introduction of a “Global Citizens” program that invites and provides a platform for “global citizens” to “lend their voice, urging governments, companies, and nonprofits to make these issues a priority”. Certainly, their big bet can only be attained by building collaborations within existing structures and breaking down walls between nonprofit sectors. Monetary and R&D investments by the private sector coupled with international political support will be paramount for achieving any progress. Political will and better bureaucracy at the country level is a huge determinant of success. However, it is noted that the letter does not focus much, if at all, on the development of structures that sustain interventions such as legal, policy, financial and governmental environments. The focus is rather on straightforward solutions that can be achieved while bypassing these systems and institutions.

All-in-all, the letter provides a credible, multi-sectoral agenda and it is hoped that the Post-2015 Sustainable Development Goals will be as practical as the 2015 Gates Annual Letter in providing achievable goals for improving global health in the next 15 years.

References:

Bill and Melinda Gates. 2015 Gates Annual letter. www.gatesnotes.com/2015-annual-letter

Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.

References:

http://www.cdc.gov/polio/updates/

https://news.vice.com/article/afghanistan-confirms-new-polio-cases-as-pakistans-outbreak-reaches-grim-milestone

http://www.theguardian.com/society/2014/sep/07/us-nearly-600-measles-cases-this-year-cdc

http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/

http://www.polioeradication.org/

http://www.washingtonpost.com/blogs/worldviews/wp/2012/10/17/taliban-polio-vaccines/

http://www.bbc.com/news/world-asia-26121732

http://www.npr.org/blogs/goatsandsoda/2014/07/28/330767266/taliban-in-pakistan-derails-world-polio-eradication

Vaccines and Gavi to the Rescue for Millions of Children

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com)

As talk continues to increase about an Ebola vaccine possibly becoming a reality in a couple months, I thought I’d offer a larger look at vaccines in general and how Gavi, the Vaccine Alliance, is helping ensure children in the poorest parts of the world can take advantage of lifesaving immunizations.

Many people have probably heard of Edward Jenner and his smallpox variolation which served to immunize people against smallpox. But this sort of variolation, taking fresh matter from a sore of someone suffering from an infectious disease and inserting that under the skin of a healthy person to cause an immune response resulting in the variolated person being immune to the disease, had been taking place in Africa, India and China long before Edward Jenner was even born.

The work done by Jenner and his predecessors were humanity’s first attempts at controlling an infectious disease through vaccination.

In the current era we have vaccinations for many of the infectious diseases that previously plagued many of the world’s richer nations, and still plague many of the poorer nations. Some may argue that we have too many vaccinations here in the West and that we are causing more harm than good through our childhood vaccinations. I’m not here to argue that particular topic with readers but if you’re interested in reading some science-based information about vaccines you can find that here, here, and here.

What I want to focus on is how vaccines have taken us from a world where millions upon millions of children died every year from infectious diseases and how the only hope for stopping an outbreak was quarantine, to a world where many of these infectious diseases are rarely seen in richer countries and are on the difficult path to being controlled in many lower income countries around the world. Now this is not to say that outbreaks of these vaccine preventable diseases such as polio, measles, and whooping cough, to name a few, are not occurring in the US, Europe, or Asia. They are, as evidenced by this interactive map from the Council on Foreign Relations.  We still have work to do that is for sure. But organizations like Gavi are focusing on eradicating these infectious diseases in middle and low income countries around the world, where these diseases exact a high toll.

So to put the effect of vaccines into perspective:

• 3 million lives are saved worldwide every year due to vaccines
• 1 child dies every 20 seconds from vaccine preventable diseases worldwide
• The United States has seen a 99-100% decrease in cases of diphtheria, measles, H. influenza, mumps, rubella, congenital rubella, polio and smallpox due to vaccinations
• Vaccines save the US $42 billion a year in medical costs and lost productivity

The incidence of many of these vaccine preventable diseases is still high in many of the poorer countries of the world; enter Gavi, the Vaccine Alliance. Gavi helps save children’s lives and protect people’s health by increasing access to immunizations in poor countries. Gavi is a public-private partnership with The Bill & Melinda Gates Foundation, WHO, UNICEF, and the World Bank. Gavi works with health ministries in 77 countries to use existing frameworks to deliver vaccines to those in need. Since 2000, Gavi has contributed to the immunization of 440 million children with another 243 million immunized between 2011 and 2015. These efforts amount to averting an estimated 3.9 million deaths from 2011 to 2015 due to vaccine preventable diseases.

Vaccines save lives; it’s as simple as that. Those vaccines we take for granted here in the US are the difference between life and death for many children in lower income countries. Gavi, the Vaccine Alliance is working to make those vaccines accessible to those who need them most.