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GAVI from the country perspective
- Gill Walt, Ruairi Brugha, Mary Starling (18 January 2002)
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CIRCUMVENTING MARKET FORCES: UNHEALTHY VACCINE PROMOTION
- Jacob M. Puliyel MD MRCP MPhil, R. K. Ozha, Jacob Abraham, Meenakshi Khosla (8 February 2002)
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Gill Walt, Professor of International Health Policy London School of Hygiene & Tropical Medicine, Keppel Street, WC1E 7HT, Ruairi Brugha, Mary Starling
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GAVI from a country perspective We would like to dissociate ourselves completely from the newspiece in BMJ 19 January, entitled 'Children's charity criticises immunisation initiative'. We were involved in the design, methods, data collection and analysis of a study entitled 'New Products into Old Systems: the Global Alliance on Vaccines and Immunizations (GAVI) a country perspective', which was facilitated, funded and published jointly with Save the Children UK. The Report looked at four countries' experience with the application process for new vaccines from GAVI, and their perceptions about funding for systems support. SC UK had a number of concerns about GAVI that went much further than the Report, but unfortunately gave the impression that these stemmed from the above Report. Specifically, we wish to draw your attention to the following: 1. The study included no criticism of the Global Alliance for Vaccines and Immunisations (GAVI) "for including managers from pharmaceutical companies on its governing board"; it made no comment on "a potential conflict of interest". 2. The reference to the "the risk of commercial, product-oriented pressure" is the expressed view of SC UK. 3. The reference to the initiative having failed to "ensure that additional resources were provided to countries with weak health systems before they take on expensive new vaccines" is an error of fact. One of the innovative features of GAVI initiative is that it did provide additional resources, up-front, to strengthen immunisation delivery. This was welcomed by all four countries, as was the initiative more generally. 4. The study made no warning about "raising poor countries' awareness of immunisation programmes". Country ministries of health are well aware of the importance of immunisation programmes, hence their welcome of the GAVI initiative. 5. The study made no suggestion that "such schemes could end up creating markets for costly new vaccines while doing little to tackle the biggest killer diseases." Vaccine-preventable diseases are among the big killers in poor countries. 6. The suggestion that the Report said "that Ghana was given only 10 days to decide whether to accept a new hi-tech vaccine for hepatitis B without any evidence that this was actually needed . . ." is another error of fact. . As stated in the report, all four countries welcomed the opportunity to introduce Hepatitis B vaccine into their immunisation schedules. . A ministry of health respondent did report that Ghana was given a 10 day deadline and decided to accept a pentavalent vaccine, which included Haemophilus influenzae B (Hib) as well as Hepatitis B vaccine. Some respondents expressed concern about this choice with regard to the availability of country-specific evidence on Hib burden of disease and future financial sustainability. Following their initial press release in Geneva on 15th January 02, SC UK issued the following statement: 'The report is based on country- specific research conducted by the London School of Hygiene and Tropical Medicine, and facilitated, funded and published jointly with Save the Children UK. . . . . The media documents and statements of Save the Children UK therefore represent the considered views of that organisation alone and not those of the London School of Hygiene and Tropical Medicine. Save the Children UK regrets any confusion it may have inadvertently created between its critique of GAVI and the analysis produced by the London School of Hygiene and Tropical Medicine." |
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Jacob M. Puliyel MD MRCP MPhil, Consultant Pediatrician and Head of Department Department of Pediatrics, St Stephens Hospital, Tis Hazari, Delhi 110054 India, R. K. Ozha, Jacob Abraham, Meenakshi Khosla
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CIRCUMVENTING MARKET FORCES:
UNHEALTHY VACCINE PROMOTION
Save the Children Fund (SCF) 1 have noted the paradox of having vaccine manufacturers (who profit from the sale of vaccines) on the governing board of an organisation meant to promote vaccine use in developing countries – the paradox of the seller being able to dictate the demand. In a market economy goods are sold at prices that cover cost of production and also yield profit to the manufacturers but which is yet competitive in the market. Buyers evaluate the cost against benefit and decide whether to buy or not to buy. If buyers are not impressed with the selling price and refuse to buy, prices come down automatically. If the selling price that a commodity commands in the market is less than its cost of manufacture, the commodity fades out of the market. The case of vaccine manufacturers is unique - they have broken lose from these market imperatives - using a subtle but potent form of blackmail. They have convinced organizations like the WHO, the Children’s Vaccine Initiative (CVI) and the Global Alliance for Vaccines and Immunisation (GAVI), that vaccine research is expensive and that new investment in vaccine research can be expected only if good returns are demonstrated in the uptake of recently produced vaccine. The onus of demonstrating cost benefit shifted from the manufacturer to the consumer - organizations like the WHO and the GAVI. It is not surprising that vaccine manufacturers sit and dictate terms on the board of GAVI. It is implied that vaccines must be supported at all costs. If benefits do not match costs, benefits are to be exaggerated, to convince nations to utilize vaccines. The SCF report suggests that the nexus between the vaccine manufacturers and agencies like GAVI is saddling the worlds poorest countries with expensive vaccines they do not even need. Evidence that this is happening can also be discerned in literature published by organisations like the Children’s Vaccine Initiative’ of the WHO. I will quote 2 instances to illustrate my point in support of the findings of the charity SCF Exaggeration of the Benefits Miller of the Children’s Vaccine Initiative2,3 suggests that 20 to 25% of hepatitis B carriers die at the age of 45 years. For this, he relies on the incidence of hepatocellular carcinoma (HCC) reported by Beasley4 in Taiwanese males (495 cases per 100,000 carrier years). It ignores the statement by the author in the report that this incidence is 3 or 4 times higher than the incidence of HCC in women in Taiwan. The real incidence of HCC in Taiwan actually works out to around 320 per 100,000 carrier years, assuming that half the population is made of women. This may be compared to the incidence of HCC in Japan (240/100,000carrier years)5 and Alaska (256/100,000 carrier years) 6. In a study in Montreal7 there were no cases of HCC where 17 would have been expected going by the Taiwan figures. It is obvious that selectively using the unusually high figures for HCC obtaining among Taiwan males, to project the dangers of Hepatitis B on the world’s population, grossly exaggerates those dangers. Promoting expensive vaccines among the poor that ‘perhaps are not needed’ In another paper, this one by Gustav Nossal of the CVI Scientific Advisory Group,8 it is suggested that 500 million doses of H. Influenza B (HIB) vaccine be used each year (4 doses to each year’s birth cohort) so that the price of the vaccine can come down.. India is home to a quarter of that birth cohort. In a paper published in Vaccine9 we have shown the existence of natural immunity to haemophilus b in Indian infants. Naturally occurring immunity has been demonstrated in healthy infants in Turkey also10. Hib vaccine is not routinely used in these developing countries at present. The suggestion that they use the vaccine so that its price can come down in the West, is enunciating the Robin Hood Principle in reverse. Vaccines represent one of the most important public health triumphs of our time. Doctors feel that on account of its ‘societal benefits’ vaccine manufacturers must be considered differently from other pharmaceuticals. However that is to prejudge the issue. Not all vaccines will have the same societal benefits. Vaccine manufacturers cannot be defence and jury in arbitrating the issue. Organisations like the WHO and GAVI must steer clear of the blandishments of vaccine manufacturers if they are to retain their credibility R. K. Ozha MBBS
Department of Paediatrics,
St Stephens Hospital,
Tis Hazari,
Delhi 110054,
India
Reference 1. Fleck F. Children’s charity criticises global immunisation initiative. BMJ 2002;321:129 2. Miller MA, Kane M. Routine Hepatitis B immunisation in India: Cost-effectiveness assessment Indian J. Pediatrics 2000;67(4):299-300 3. Miller A, McCann L. Policy analysis of the use of the hepatitis B, haemophilus influenza type B, streptococcus pneumonia-conjugate and rotavirus vaccines in national immunisation schedules. Health Economics 2000;9:19-30. 4. Beasley RP. Hepatitis B virus. The major aetiology of hepatocellular carcinoma. Cancer 1988;61:1942-56. 5. Sakuma K, Saitoh N, Kasai M, etal. Relative risks of death due to liver disease among Japanese male adults having various statuses for hepatitis B s and e antigen in serum: a prospective study. Hepatology 1988;8:1642-46. 6. McMohan BJ, Alberts SR, Wainwright RB, etal. Hepatitis B related squeal: prospective study of 1400 hepatitis surface antigen positive Alaska carriers. Arch Intern Med 1990;150:1051-4 7. Villeneuve J-P, Desrochers M, Infante-Rivard C, etal. A follow up study of asymptomatic hepatitis B surface antigen-positive carriers in Montreal. Gastroenterology 1994;106:1000-5. 8. Nossal G. Living up to the legacy. Nature Medicine1998;5:475-6 9. Puliyel JM, Agarwal KS, Abass FA. Natural immunity to heamophilus b in infancy in Indian children Vaccine 2001;19:4592-4. 10. Tastan Y, Alikasifoglu M, Ilter O, etal. Natural immunity to haemophilus type b among healthy children in Istanbul Turkey, Indian Pediatr. 2000;37:414-7 |
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