A young child receives the new pneumococcal vaccine in Nicaragua.
Any parent knows the scene very well: a practitioner tears open the packaging on a new syringe, pierces the top of a medicine bottle and draws just the right amount of fluid.
There’s a quick swab with a prep pad on a tiny upper arm, while child watches fascinated, often unaware of what’s about to happen.
The needle is gently inserted, and there’s a momentarily delay, until the tiny face creases in an unhappy mixture of shock and pain.
This past weekend I watched the scene repeated over and over, in a crowded neighborhood in Managua, Nicaragua, and a simple wooden church in a farming area well away from the capital.
The vaccinations were not the only business at hand. President Daniel Ortega’s political party, the Sandinista Front for National Liberation, added dance music, clothing distribution, and subsidized food sales to sweeten the experience in the final weeks of a national political campaign.
The records were kept by hand, health histories, names and dates taken. In places with no doctors the community health fairs are a time to get expert advice on a variety of health problems. Young doctors listen sympathetically over the din of blaring music, take notes, and hand over prescriptions. This is the way health care is delivered to poor people all over the world.
If you stopped Americans on the street and asked if children should be allowed to die for want of a few dollars worth of medicine, you would probably find many who would recoil at the notion. Though our health care debates are intensely focused on money, there’s also a sense that quality and availability shouldn’t solely be delivered to people of means. A way should be found, must be found, they might suggest, to make sure unnecessary deaths don’t happen, especially among children.
But every time you add variables the “how” gets more and more complicated. The NewsHour’s global health unit just spent a week in Nicaragua, taking a look at the national rollout of a vaccine for pneumococcal pneumonia. The disease is common in Nicaragua, and it’s the largest single cause of death in children under five. Along with the thousands of deaths each year in Nicaragua, an estimated half a million deaths from the disease happen each year worldwide in children under five. A safe and effective vaccine came to market in the last several years, at a stunning $100 per dose.
At that price, Nicaragua certainly couldn’t pay to vaccinate all its children. After making large upfront investments in the development of the vaccine, Pfizer, Inc. was unlikely to simply donate all that medicine. Nicaragua is the second-poorest country in the Western Hemisphere, sitting behind only Haiti on that list at a little more than $1,000 a year gross national income per capita. By contrast, the gross national income per capita in the United States is roughly $47,000.
It is a rough, straightforward reality of life on planet Earth as the seven billionth human joins our extended family: a child unlucky enough to be born to extremely poor parents will die of things few children will die from in the richest countries. That truth is so deeply internalized we rarely even talk about it. But the gap is so huge it might give you pause. A Nicaraguan child who contracts the bacterium that causes pneumococcal pneumonia is 200,000 times more likely to die from the disease than a child in the United States. Two-hundred-thousand times!
The GAVI Alliance, formed as the Global Alliance for Vaccines and Immunization, worked to find a way to close that yawning gap between great danger to children and a life-saving medicine, between deep poverty in Nicaragua and Pfizer’s high costs. An Advanced Market Commitment, with GAVI as the middle-man, gets Nicaraguan children and a multinational pharmaceutical company what they need.
The organization pools private and government donor dollars, and wins long-term commitments from recipient countries to acquire and deliver the vaccine. By doing this, GAVI gives business a predictable outcome for sales of a vaccine, something it might not otherwise have. Recipient governments, like Nicaragua, get massive discounts in return for their long-term assurances of a market. In the case of pneumococcal pneumonia vaccine, the price moved from roughly $100 to $3.75 cents. Even at that price, it still represents a major commitment for very poor countries, but one with immediate and visible returns.
For the organizations that have pulled this off, the beauty of it is engineering widespread health benefit while still making the numbers add up for manufacturers. Dr. Seth Berkley, CEO of the GAVI Alliance, explained it this way, “In the past, a new vaccine would appear in the West. It would be quite expensive. There would be no purchasing of that vaccine in the developing world. Even if there was, because of the fact that there wasn’t an intermediary, the price wouldn’t necessarily be at a level that they could get to.
“So GAVI comes and says, ‘What we’d like to do now is supply a large number of countries and we’ll provide a market. We’ll be able to tell you how many doses we need.’ That is important for vaccine production because it takes a number of years to build up the production capabilities for it. By giving this Advance Market Commitment, the donors made it quite attractive to the companies to enter this space. All of that together really encouraged those companies, and the longer term goal is to try to create a market that’s healthy.”
Dr. Orin Levine spent time in Nicaragua watching the nationwide vaccine rollout. He is the executive director of the International Vaccine Access Center, a recognized expert on pneumococcal pneumonia and a professor at the Bloomberg School of Public Health at Johns Hopkins University in Baltimore. For him, one of the most important aspects of the initiative is that shortened timeline for a new medicine’s introduction among the poorest patients.
The benefits of a big breakthrough in medicine, Levine says, come when science “brings about social justice when it essentially eliminates the kind of disparities in risk that children in poverty face. So by virtue of the fact that we can now get life-saving pneumococcal vaccines to children in Nicaragua the same time we get them to children in Newark, we are making a huge impact on those children on their families and on their communities.”
When a new vaccine is available for a deadly disease like pneumococcal pneumonia, you don’t even have to vaccinate everyone in the society, Dr. Berkley explained.
“You vaccinate enough people, and you end up having and effect on the whole population,” he said. “We saw that when Homophilos Influenza type B vaccines were rolled out in the United States. By the time they started rolling out, and got to about 40 percent coverage, we saw a plummet in the number of cases, and this was because the bacteria stopped getting spread from child to child and therefore it had a much bigger effect.”
Epidemiologists at the Managua office of the Pan-American Health Organization are still waiting for hard data from the vaccine introduction, but what they have seen so far leads them to conclude the new shot is a success.
In the moment, that’s little comfort to the wailing little boy now squirming in his mother’s lap. You feel like tapping him on the shoulder and saying, “Kid, this woman with the needle may have just saved your life.”
Read more from the NewsHour team in Nicaragua on our Global Health page.