Achieving the impossible with vaccines

As India’s eradication of polio proves, the impossible is often in closer reach than it appears, writes Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance

When the Government of India announced in 2014 that it had successfully eliminated polio from the country, Dr Margaret Chan, who was director-general of the World Health Organization at the time, said that “India has shown the world that there is no such thing as impossible”. And indeed, looking at the statistics from 2009, just five years prior, that is exactly how this goal would have looked – impossible. India was a country of 1.3 billion people carrying 60% of the global disease burden, with millions living in extreme poverty with poor sanitation. Yet they did it. India has not seen a single case of wild polio virus since 2011.

This story is a reassuring one to keep in mind as the global health community reaches for another seemingly impossible goal: universal health coverage, where good-quality and affordable health care is available to every person, everywhere, no matter what their income. It illustrates what can be done with strong political commitment, with community engagement and with strong surveillance systems. But it also illustrates the power of a very simple, almost ubiquitous public health intervention: vaccines.

In 2011 alone, 900 million doses of oral polio vaccine were administered in India. This was made possible by a team of 2.3 million vaccinators, the support of religious leaders and thousands of community mobilisers, and heavy investment from the Government of India in surveillance. To achieve elimination, vaccinators needed to reach communities that had been chronically neglected by public health services.

They needed supply chains, cold storage, community outreach, and meticulous healthcare records and planning. Through this effort, the Government of India, the World Health Organization and partners did not just eliminate polio: they created a vast infrastructure that is now proving invaluable in delivering other essential health services. Because of this, the polio elimination effort is now helping to deliver a range of other vaccines, as well as vitamin A supplements, zinc, oral rehydration salts and reproductive health services.

In other words, the impact of vaccines goes far beyond their ability to protect against specific deadly infectious diseases.

Routine immunisation reaches more people worldwide than any other health intervention, including those living in some of the hardest-to-reach communities on the planet. It is the only intervention that brings the majority of children and their families into contact with primary health services five or more times during the first year of a child’s life. In 2017 alone, vaccines created 550 million touchpoints in countries supported by Gavi, the Vaccine Alliance. This makes immunisation an ideal platform to improve access to primary health care and ultimately work towards universal health coverage.

The contribution that vaccines make towards improving health for all goes further than just logistics. Prevention is not only better than the cure: it is also cheaper. Vaccines offer a better return on investment than any other public health intervention: for every $1 invested in immunisation, $16 is saved in healthcare costs and lost productivity. This rises to $44 when taking into account the broader benefits of people living longer, healthier lives. Part of this return on investment is thanks to the role vaccines play in protecting families from medical impoverishment. According to research published in

Health Affairs in 2018, vaccines administered between 2016 and 2020 will prevent more than 21 million people from slipping into poverty in 41 of the world’s poorest countries. With finite resources to draw from and conflicting priorities, efficiency will be key to achieving universal health coverage. Governments can be confident that when they put money into vaccines, that money has been well spent.

Gavi – the organisation I head – is working to reach every child in the world’s poorest countries with these lifesavers. It is a huge challenge: rapid urbanisation, population growth and human migration mean we are chasing a moving target. Each year we start afresh with a new and larger cohort of children born, so that even maintaining the progress in coverage already achieved cannot be a given.

To reach more children, we are increasingly harnessing the latest technology from drones to biometrics, and constantly looking at where we can collaborate with other organisations to reach our common goals. By doing so, we are laying the groundwork for the provision of broader health services. There are also lessons to be learned here when it comes to reaching universal health coverage: it will require a concerted global effort from a huge range of partners, making the most of 21st century technology.

Gavi is also investing money and expertise in strengthening health systems, working to reach unreached communities and identifying best practices to integrate other health services into immunisation programmes. The benefit of this goes both ways: expanding immunisation systems can improve access to primary health care, and stronger primary healthcare systems can boost vaccine delivery.

There is no doubt that universal health coverage is an ambitious goal. But if the enormity of the task had put India off tackling polio, that one country might still be seeing as many as 200,000 cases a year – as it did in the 1970s – rather than zero. India took on a seemingly impossible goal and, with vaccines, made it possible. Now let’s do the same for universal health coverage.