Bill Gates loves vaccines.
He says so all the time. The media, as well as the social media hipsterverse, regularly report on this love affair, usually cheering along with Gates in favor of the cause of polio eradication — a cause which was advanced recently at a meeting he and other glitterati convened in Abu Dhabi, the world’s richest city.
Gates says the very foundation of his foundation comes from his realization in the 1990s that kids were dying for lack of access to a vaccine we in the rich world take for granted. As a result, boosting vaccination worldwide became the prime mover, the raison d’être, for what would soon be the world’s biggest philanthropy.
Yet few appreciate today just how revolutionary, and unlikely, was the start of this love affair.
Promoting this powerful, fundamental tool for children’s health may look now like an obvious humanitarian thing for a philanthropist to do. But it wasn’t either obvious or that celebrated when the Bill & Melinda Gates Foundation started down this path (pun intended) in the 1990s.
The Gates Foundation’s push for a revolution in immunization was greeted, from the outset, by a weird combination of controversy and apathy.
It was controversial because a Seattle billionaire software geek was taking over a fundamental job that many in the global health community thought they owned. People didn’t like this, but usually only said so privately. Carol Bellamy of UNICEF was an exception, who honestly and openly swore at me when I interviewed her about this massive, new effort out of Seattle to take on the job of getting more kids vaccinated.
“It changed the power dynamics and threatened some people’s turf,” said Amie Batson, PATH’s chief strategy officer. Batson was an immunization specialist at the World Bank when GAVI was launched in 2000 and remembers how controversial it was within the global health community. “It was a huge deal … The Gates Foundation really shook people up, in part because suddenly there was this large amount of money ($750 million, initially) put into this nobody had ever seen before.”
Despite the drama in global health circles, apathy was the predominant response by the media (a rare exception for a time was my employer, the Seattle Post Intelligencer) and the general public. Nobody cared much about vaccines in the late 1990s. And this was having a deadly impact in the developing world.
“Immunization rates in many poor countries were declining, or stagnating at best,” said Orin Levine, an epidemiologist, pneumonia doc and the new chief of vaccine delivery at the Gates Foundation. “It was not a good time.”
Part of the problem is that vaccines are, well, boring (unless you are among the hysterical who think they cause autism). Vaccines don’t or cure treat disease; they prevent it. Boring. For the most part, the public ignored what the Gates Foundation was doing.
Many saw the entire idea of the new Gates Foundation back then as a public relations stunt given that Gates was viewed as a ruthless businessman fighting the feds on monopoly charges. Yet it’s obvious to all now that this Gates global health thing turned out to be real and truly revolutionary.
What has some worried now is that this well-intended and massive revolution focused on immunization, as designed and driven by a relatively small but powerful number of players in Seattle, has set the world on a course that some think may not be sustainable.
“The Gates Foundation has had a tremendous and beneficial impact on vaccinations globally,” said Kate Elder, with Médecins Sans Frontières (MSF), aka Doctors Without Borders. “But this has been done by exerting a lot of influence over the global health strategy, in a way that doesn’t always allow for a lot of open dialogue and debate.”
The Gates Foundation, Elder said, has favored an approach which MSF thinks is a bit too beholden – if not downright obsequious – to the drug industry.
It’s one of those ‘public-private partnerships’ that everyone likes to like but which sometimes ends up benefiting the private side at the expense of the public, Elder says. This what MSF thinks is happening with the Gates Foundation grand vaccine plan. Here’s an MSF video in which they try to make the even more boring issue of vaccine pricing somewhat entertaining:
The Gates Foundation definitely deserves credit for boosting access to new immunizations worldwide, Elder said, but this is being done in a way that places the drug industry’s need to make a profit on vaccines first and the needs of the poor second.
“That’s just wrong,” said Seth Berkley, CEO of GAVI, the Global Alliance for Vaccines and Immunization (the Gates Foundations’s largest single project, in terms of dollars, launched in 2000).
Vaccines do need to be priced so poor countries can afford them, Berkley said, which is what GAVI is all about. “But we also need this to work for industry, since they make the vaccines. It’s a balancing act.”
In the late 1990s, many donors, rich government aid agencies and even organizations like UNICEF had shifted more of their attention — publicity, marketing — to more exciting humanitarian causes. Most drug companies had no interest in selling vaccines in poor countries due to the low profit margin. As a result, past gains made by immunization champions like UNICEF’s Jim Grant, who was one of those who had helped greatly expand developing country vaccination rates in the 1980s, were unraveling.
GAVI was launched by the Gates Foundation to turn this around and correct the ‘market failure’ of vaccination, Berkley said. Its focus was on putting money up front for developing new vaccines to reduce the drug industry’s financial risk, he explained, in return for creating affordable vaccines offered specifically to poor countries at discounted rates.
“When we started, we had six (basic childhood) vaccines and now we have 11,” Berkley said. This has increased the cost from the original package of six costing about $1.50 to anywhere from $23 per child (GAVI’s estimate) to $38 (MSF’s estimate) for the 11 vaccines today. That’s the 2700% increase MSF is complaining about and which Berkley dismisses as an unfair critique.
“Yes, it costs more. But that’s like moving someone from living in a cardboard box in a slum into a house and then hearing him complain the roof cost too much.”
Actually, says Elder, it’s exactly like that. The concern MSF has with the GAVI approach is that it is moving poor countries into a vaccination scheme they cannot afford without the current subsidies. Many will soon ‘graduate’ from the GAVI subsidies and be facing these vaccine costs on their own.
“The two newest vaccines, for pneumonia and rotavirus, account for 70 percent of the cost,” Elder said. “This is an alarming trend, these increasingly expensive vaccines, that we believe will be unsustainable for the countries that need them the most.”
Berkley disagreed, noting that the reason some countries will no longer get subsidies is due to their economic improvements. Further, he said, the economies of scale means that as more countries put these vaccines into use GAVI may be able to further negotiate down prices. Prices for some vaccines have already declined, Berkley said, noting that the ‘pentavalent’ vaccine (against diptheria, tetanus, pertussis, haemophilius influenza and hepatitis B) has dropped from $3 to about $1.
“And we were able to get the pneumococcal vaccine down to about $3.50,” Berkley said. “This is normally a very expensive vaccine … Yes, industry is still making money. If they don’t make money, they won’t do it.”
Elder said the problem is we don’t know how much money they are making since industry refuses to open its books. MSF, which is a member of the GAVI alliance, had asked partners to agree to vaccine price monitoring to develop norms and standards for the community. MSF has also urged the drug industry to make its profit margins on these vaccines known so the community can see that the profits are modest.
Industry and the GAVI leadership has not acted to incorporate this kind of vaccine price accountability into its practices or as a principle for the Global Vaccine Action Plan – an over-arching strategy led by a group convened by the Gates Foundation called the Decades of Vaccine Collaboration.
“We’d like to see more of this information made public,” said Elder, referring to both the price calculations as well as the development of global vaccine policy.
(Note: The Decades of Vaccines Collaboration has been portrayed as an organization created to advocate the cause of immunization. It is that, but it was also created by the Gates Foundation in part to serve as a counterpoint to GAVI when that organization was being run, prior to Berkley’s tenure, in a manner that displeased the Seattle philanthropy. The split has since been repaired.)
“I think people have forgotten what it was like before GAVI,” said Batson. “It used to take 10 or even 20 years for a new vaccine developed for use in the West to get introduced in the developing world because of the time it took for the price to drop … We were told we were crazy to think we could get new vaccines introduced this quickly and cheaply. Are they still too expensive? I think that’s a very subjective question.”
Levine said MSF, GAVI and the Gates Foundation all want the same thing – the most kids vaccinated for the least money.
“Can we do better at bringing prices down? Absolutely,” said Levine. But it’s a process, he said, that must address the needs of all players – the poor as well as the drug industry. Of equal concern to keeping vaccines cheap, Levine said, is to do a better job of vaccinating more children.
“I think it’s fair to say we’ve been very successful at speeding up access to new vaccines,” Levine said. “We’ve been much less successful when it comes to expanding routine vaccine coverage.”
Elder agreed, saying: “There are still 22 million children being missed with basic vaccines and most of those kids are in the poorest countries. I don’t think the strategy of GAVI, of the Gates Foundation, is doing that much to close this gap.”
Berkley and Batson also agreed on this point, that the Gates Foundation strategy on vaccination has improved access to new vaccines but has perhaps done little to strengthen basic public health systems in poor countries and expand access to existing vaccines. That was one of the anticipated benefits of GAVI when it was launched, that by boosting investment and interest in new vaccines poor countries would invest in basic health system improvements (like routine vaccination).
This didn’t happen, at least not to the extent hoped.
“But what’s exciting is that the community recognizes this now and it is a priority,” said Berkley.
MSF’s Elder responded by saying, basically, talk is cheap. This was supposed to have been a priority from the beginning of the Gates Foundation’s approach on immunization, she said. Improving routine immunization is now clearly a higher priority, she said, which has come about largely because GAVI has learned and adapted. Given the trends on vaccine prices, Elder said, she would hope the other lesson learned is that we need a new approach to negotiating vaccine prices.
“I think we can do a lot better and that should start with making industry more accountable.”