Bill Gates
Bill Gates, the founder of Microsoft and a co-chairman of the Bill and Melinda Gates Foundation released an open letter that looks back on 2009 and ahead to future challenges and possible solutions. The letter includes the text below. He addressed what he called the “miracle of vaccines.”
“The focus of this year’s letter is innovation and how it can make the difference between a bleak future and a bright one. …
“2009 was the first year my full-time work was as co-chair of the foundation, along with Melinda and my dad. It’s been an incredible year and I enjoyed having lots of time to meet with the innovators working on some of the world’s most important problems. I got to go out and talk with people making progress in the field, ranging from teachers in North Carolina to health workers fighting polio in India to dairy farmers in Kenya. Seeing the work firsthand reminds me of how urgent the needs are as well as how challenging it is to get all the right pieces to come together.
“One particular highlight from the year came last summer, when I traveled to India to learn about innovative programs they have recently added to their health system. The health statistics from northern India are terrible — nearly 10 percent of children there die before the age of 5. In response, the Indian government is committed to increasing its focus and spending on health. On the trip I got to talk to Nitish Kumar, the chief minister of Bihar, one of the poorest states in India, and hear about some great work he is doing to improve vaccination rates. …
“I am optimistic that innovations will allow us to avoid these bleak outcomes. In the United States, advances in online learning and new ways to help teachers improve will make a great education more accessible than ever. With vaccines, drugs, and other improvements, health in poor countries will continue to get better, …
“Although innovation is unpredictable, there is a lot that governments, private companies and foundations can do to accelerate it. Rich governments need to spend more on research and development, for instance, and we need better measurement systems in health and education to determine what works.
“We have a framework for deciding which innovations we get behind. A key criterion for us is that once the innovation is proven, the cost of maintaining it needs to be much lower than the benefit, so that individuals or governments will want to keep it going when we are no longer involved.
“Overall we have about 30 innovations we are backing … we are funding vaccines for several diseases (malaria, AIDS, tuberculosis, etc.)
“The improved health of children in poor countries is a great example of the power of innovation. In 2008, for the first time fewer than 9 million children under age 5 died. In 2005, the last time the number was measured carefully, it was just below 10 million. This is huge progress, and it is due to improvements like increased vaccinations and better malaria treatment and prevention.
“Vaccines are a miracle because with three doses, mostly given in the first two years of life, you can prevent deadly diseases for an entire lifetime. Because the impact is so incredible, vaccines are the foundation’s biggest area of investment — more than $800 million every year — and the return is substantial. We are working to get other donors to put more resources into vaccines because we still have big challenges. The first challenge is to invent them, and the second is to make sure they reach everyone who needs them. Achieving full coverage is hard in poor countries, where cost and delivery are big barriers.
“Various innovations can simplify the delivery. Sometimes it’s possible to combine different vaccines into one. A great example of this is the vaccines for diphtheria, tetanus and pertussis (whooping cough). They were first introduced in the 1920s. In 1942 they were combined into a single vaccine, called a trivalent vaccine because it has three active elements. The price of all three doses of this vaccine is now less than 50 cents, and over 77 percent of children in the poorest countries of the world get all three of the doses they need to be protected. Since the trivalent vaccine was introduced in developing countries, tetanus deaths are down nearly 88 percent and pertussis deaths are down 70 percent. Almost all deaths from the three diseases would be stopped altogether if vaccine coverage were improved to 95 percent everywhere.
“Even when a vaccine can’t be combined with others, you can still improve distribution by making it free for poor countries, or cheap enough that they can afford to buy it. This has been a key focus for the GAVI Alliance, which we helped create almost 10 years ago. GAVI gives grants to poor countries to improve vaccine coverage and to help pay for new vaccines.
“GAVI has worked to get two new vaccines into widespread use since it was started. One prevents hepatitis B, an infection that eventually causes liver cancer in adults and kills over 600,000 people per year. The other prevents HiB (or Haemophilus influenzae type B), a type of bacteria that causes meningitis and other life-threatening problems during childhood. By the end of 2008, 192 million children had received the hepatitis B vaccine and 41.8 million children were protected against HiB.
“Now the hepatitis B and HiB vaccines have been combined with the trivalent vaccine to create a vaccine with five active elements — a pentavalent vaccine. GAVI’s work in helping to provide both the standalone and pentavalent vaccines has raised hepatitis B coverage to 68 percent of newborns and HiB coverage to 24 percent of newborns in the poorest countries.
“Cost is still a problem. Today a full set of doses of the pentavalent vaccine costs over $8 more than the trivalent vaccine. But as manufacturers produce more vaccine and additional competitors come into the market, the cost premium should drop by half in the years ahead. This is why the global health community has a goal of raising coverage of HiB vaccine to over 80 percent by 2015, which could then save 250,000 lives per year in the poorest countries in addition to eliminating lots of suffering and disability.
“This year the foundation helped launch a new approach to encourage a high-volume, low-cost supply of a pneumococcus vaccine that meets the needs of poor countries. This approach is called an advance market commitment, and it involves a group of donors pledging $1.5 billion to help pay for the vaccine for poor countries. We expect that manufacturers will commit to building factories much earlier than they would otherwise in order to compete for this money. During 2010 the negotiations with manufacturers should come to a conclusion. We believe this will make a big difference in how quickly this vaccine gets to poor children and show how this approach can be applied to other medicines.
“To eradicate the disease, we will almost certainly need a malaria vaccine, which is the highest-risk malaria work we fund. The key here is that researchers are pursuing a lot of different ideas, so that if one fails, there are still several other options. One partially effective vaccine candidate, known as RTS,S, has started its Phase III trial, which is an important step. Other vaccine approaches are at an earlier stage and they also look very promising. Scientists are combining some of these other vaccine efforts with RTS,S to raise its effectiveness and duration, an approach that could lead to a highly efficacious vaccine in eight to 15 years.
“Polio is down to fewer than 3,000 cases a year—a 99 percent reduction in 20 years—but getting rid of the last 1 percent is the hardest part of eradicating a disease. When we increased our investment in polio two years ago, we viewed it as a challenging delivery problem rather than something requiring a new tool, because the oral vaccine worked quite well. Most of our funding has supported innovative approaches to delivery. But when we saw that in some places the oral vaccine wasn’t totally effective, we also funded the creation of new forms of the vaccine that are targeted at subsets of the three different varieties of polio virus.
“This is a good example of needing to stay open-minded about the best approach to solving a problem, because the new forms of the vaccine have been critical in the progress that has been made this year.”
“In last year’s letter I mentioned that there are four countries that account for most of the remaining cases. One was Nigeria, particularly in its northern states, where polio has been especially problematic. In 2009, thanks to new money and political support from some state, local, and traditional leaders, they were able to vaccinate more children in most states. This led to a 50 percent decline in the overall number of cases and a 90 percent decline in the most virulent strain. In 2010, they will need to get the vaccination rate up in every state.
“The three other countries—India, Afghanistan, and Pakistan—shrunk the geographical areas affected by the virus. Some of the toughest remaining areas are the ones where the security situation is bad, like parts of Afghanistan and Pakistan.
“When outbreaks did occur, countries responded faster and more effectively than they had before. Last year, poliovirus from Nigeria and India spread to more than 15 African countries that had been considered polio-free. But because many countries had begun using better laboratory techniques, they identified the virus quickly and started immunization campaigns right away, which limited the spread of the outbreak. Still, we haven’t gotten these countries back to zero cases yet, especially in west Africa and Chad, where the outbreak is still widespread. I will be traveling to some of these countries to meet with health leaders, and I expect I’ll be able to report even more progress in next year’s letter.”
To read the entire letter, which also addresses issues including childhood deaths, agriculture and online learning, visit http://www.gatesfoundation.
