Relentless pursuit of an equitable world

The Optimist

Three children running in desert

Keeping vaccination goals close, no matter how afar

In the week that WHO and UNICEF released a new report on progress toward global immunization coverage, Dr. Orin Levine, director of vaccine delivery at the Bill & Melinda Gates Foundation, explains to The Optimist that for him the numbers represent more than statistical analysis. They also trigger memories from almost three decades working in global health.


Frontline Health worker Humayse Ashab discusses daily activities with Orin Levine, at the Udale Daba Kebele health post in the Udale Daba Kebele, Afar region, Ethiopia. November 19, 2015.

World Family

International travel is good for the soul. It gives you perspective when you leave your bubble. You think, Holy cow, I've been taking for granted a lot of things. In 1987, I went to Kenya for a semester of undergrad. They paired me with a Kenyan family in Kibera. I had two surrogate Kenyan sisters – Bonnie and Emma, one about my age, the other fifteen years young – the same age as my little sister back home. Living in Kibera was an eye-opener.

While our family shared a small home with running water and indoor toilet, we were in a community where many families were crowded into much smaller homes, often built of mud, and many without access to water or sanitation indoors. We lost touch over the years, but we reconnected again on Facebook.

View of Kibera in Nairobi, Kenya
View of Kibera in Nairobi, Kenya.

I visited them in 2011, when I went back to Kenya for the launch of the pneumococcal vaccine. As we caught up on life, I observed that my youngest Kenyan sister was pregnant and looked ready to deliver any time. It wasn’t evident when she was due, but she kept leaning back, feeling uncomfortable. We had a great time and when I left, we agreed to stay in touch.

Two days later, I was at Mbagathi Hospital, nearby, to film a video on the prevention of pneumonia in Kenya. As we were walking the hospital floor, I saw my Kenyan sister in the delivery ward with her newborn. It was a moment where my life’s work and life’s journey intersected. I thought about how that baby boy, born that day, would get the pneumococcal vaccine. It felt like I had made a small contribution back to his family—my family.

Vaccine Equity

We’re making great progress on vaccine coverage, globally. A new study from my old shop at Johns Hopkins estimates that we’ve prevented 1.45 million deaths since 2000, just by treating kids with the Hib and pneumococcal vaccines. We’re introducing new vaccines at a speed and scale unheard of in the 1980s and 1990s. We’re extremely close to eradicating polio – the virus is cornered and there was a record low number of cases last year (22). We’re also preventing 2 to 2.5 million deaths a year thanks to routine immunization.

These are all amazing achievements, but that doesn’t mean the work’s finished. What keeps me up at night is the inequity of vaccine coverage. I have two kids. I feel a visceral connection when I see kids with pneumococcal disease in developing countries. They didn’t get the same vaccines my kids did, because I live in a rich country, and they don’t. And now they’re in the hospital. That’s not right.

Something that appeals to me about the polio eradication program is that they will only be satisfied by achieving absolute zero occurrence of the disease worldwide. That drives them to work out how to get the vaccine to places where, if the goal was to be close to zero, they might decide are too difficult to reach. I’m frustrated that we don’t take the same approach with routine immunization programs.

Reaching Afar

A couple years ago, I went to Ethiopia’s northeastern province of Afar, which is home to roughly 1.8 million people. It has really low immunization coverage rates – like 20 to 30 percent. Visiting Afar felt like I had dropped into the Biblical era. It was dry desert and sparsely populated. People lived in rudimentary huts and I saw mothers with their kids leading camels to find water to drink. Families there move around a lot with their animals. At the local health center, there was a really committed and competent person struggling to get to all those disparate communities. Communities that we always seem to leave to the very last, and sometimes don’t even make the effort to reach at all.

When I look at those populations, I want to do better for them. But we can’t just work a little bit harder with more of the same approaches. There are unique characteristics in these communities that we need to think about. How do we get people to care about these out of sight, out of mind rural populations in the first place? Then, once they care, what tools do they need to be sure they can reach those people?

We’re working with Gavi to eliminate supply chain logistics as a barrier to immunization. Vaccines need to stay between a certain temperature to be safe and effective, yet we’re often asked to deliver them in an environment where there’s no electricity and it’s blistering hot. Anyone who has been on a picnic and tried to keep their food cool will understand the difficulty of the “cold chain.” Through the hyper-engineering of thermoses and refrigerators, we can now keep vaccines cold and avoid freezing them at the same time. This sweet spot is a product of technological innovation that’s been really incredible.

The (Cold) Chain Reaction

I like the idea that the hard-to-reach places push us to design new technologies that force the limits of what we have ever needed before. What’s even more inspiring is that when we put these life-saving tools into people’s hands, they make even more of them through their own creativity. When the Arktek cooler was developed and field tested in Ethiopia, the people in a remote community hitched it to a camel and took it on a multi-day outreach trip. In the Democratic Republic of Congo, people started strapping the Indigo onto their motorcycles. The technology provided the opportunity to expand vaccine coverage, the ingenuity of the local people made it happen.

Man with camel
Photo courtesy of Dylan Vecchione & Intellectual Ventures.

The point is: You design something to be used one way, but once you give it to people, they get creative and come up with different ways to use it. I like unlocking potential through innovative, largely disruptive technology that gives people the freedom to imagine a different way of doing things. It’s important to remember that it’s not about the innovative technology itself. It’s about what the innovative technology enables people to do in pursuit of reaching the people they serve.

Vaccine Hesitancy

But increasing vaccine coverage is not just a supply problem. Even when you get vaccines to communities, success isn’t always guaranteed. We’ve discussed so-called vaccine hesitancy at the foundation ever since I arrived in 2012 and always decided that vaccine hesitancy wasn’t a priority for us. Between a constrained budget and competing priorities, we classified hesitancy as a concern but not a problem. In many of the places where the foundation works the burden of vaccine-preventable diseases is so heavy that we have strong vaccine demand.

When you see a meningitis outbreak in Nigeria and offer a vaccine, people will stand in line for hours in extreme heat to get immunized. They understand how awful these diseases are, and this drive to protect kids against preventable disease exists in many countries.

That said, as a vaccine program succeeds and more communities are protected, some people become susceptible to fears about the vaccines rather than the diseases themselves. It happens when they lose their memory of how bad these diseases can be. I’m reluctant to offer a prescription for how to address this. Reflexively, we want to offer science, evidence, and data to show vaccines work. But this won’t necessarily hit home with people. The root cause is a breakdown of trust in institutions. Vaccine hesitancy is undoubtedly an emerging problem; what to do about it is less clear.

The 90/80 Rule

The north star for us in the next decade will be to focus on making sure we’re being equitable with our coverage areas. When we signed up for the Decade of Vaccines goal of preventing 11 million deaths, we focused on where those 11 million deaths came from. Sometimes, that drove us to try to increase coverage by a few percentage points in very big populations instead of looking at the handful of remote districts where can as low as 20 percent. Unintentionally, it meant that sparsely populated places like Afar were not getting the same priority as places with big populations, such as India. At the Gates Foundation, we say “all lives have equal value,” but our goal of 11 million inadvertently drove us to work in the largest populations not the least equitable ones.

So, now we set three goals, not just one. For the vaccine delivery program at the foundation, our goals are: prevent 11 million deaths, support the eradication of polio, and drive highly-equitable vaccine coverage. We measure the last part as 90 percent coverage nationally, and at last 80 percent in every district. Because it turns out, if every single community in the world had 80 percent immunization coverage, not only would you save boatloads of lives, you’d succeed at or come really close to snuffing out transmission for a lot of diseases. And you do it by driving yourself to solve the hard problems like getting to those small, remote, left-behind populations in Afar.

I think we’ll be walking the walk on equity as a vaccine community when we view subnational data at every single meeting, when we never summarize vaccine coverage in a country with a single number. We’ll be walking the walk when we redeploy assets from places that are high coverage to places that are low coverage. And when we continually visit those places and say, “You were at 25 percent coverage last month. What are you doing this month to improve and is it working?”

That’s why, last year, we urged the WHO to start characterizing immunization coverage at a much more granular level, so we know where we are on the road to that 90/80 goal. Today, only about 20 percent of countries meet or exceed the 90/80 target. There’s a long way to go, and a lot of questions to answer. For example, what do you do in places where governance is failing and entire communities are not getting basic services of any kind? Data and new technologies alone aren’t going to get the job done. Driving management and accountability in a broken system is very tricky. There’s no overnight solution.

Patient Optimism

We talk a lot about being impatient optimists at the foundation. For this work, we need to be patient optimists. It’s about working with our partners to strengthen the social contract between communities and the people that are supposed to serve them. To succeed at that kind of systems change, we’re going to have to be prepared not only to work in really challenging environments, but to fail over and over until we get it right.

About the Author

Ryan Bell
Ryan Bell is a journalist whose pieces have appeared in publications such as National Geographic and NPR.

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