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Speech by Anthony Lake, UNICEF Executive Director, at Institute of Medicine Annual Meeting

“Reaching the Fifth Child: Immunization and Equity”

Washington, DC, 17 October 2011

Thank you, Dr. Boufford, for that kind introduction, and, all of you for inviting me to join you this morning.  I am a big admirer of the Institute of Medicine – because of the guidance you offer to advance public health – and because of the time you all volunteer to do so.  A true public service.

 Today, you have volunteered your time once again – and dedicated your annual meeting – to discussing a subject of great importance … to the medical community, to the development community, and to millions of children’s lives: Immunization.

For few things have had a greater impact on global public health than vaccines.  And few things today offer a more cost-effective way to save lives … to strengthen societies … and to shape the future of human health.

So this morning I would like to discuss the state of immunization coverage – how we got here, and the work that lies ahead if we are to reach those children in greatest need and at greatest risk. 

Doing so is both a moral obligation and a practical imperative.

New vaccines are making it much easier to achieve results in communities where afflictions like diarrhea and pneumonia kill the greatest number of children.  And, in turn, our global vaccination campaigns – to eliminate diseases like polio and measles – cannot succeed without reaching those communities. 

To put it in development-speak, an equity focus on the most in need depends on immunization, and immunization depends on an equity focus. 

Indeed, the power of vaccines helps make it possible to rethink our development strategies in fundamental ways. 

For a long time – and still today – most development experts have believed that it is simply too expensive to focus on the hardest to reach children.  They should take another look at their conventional wisdom.

Last year, UNICEF released a study which showed for the first time that the benefits of focusing on the poorest children – an equity approach – outweigh the additional costs of reaching them.  For example, in low-income, high-mortality countries, every additional dollar invested in reaching the most vulnerable children can avert up to 60% more child deaths than the current approach. 

This is a highly significant finding, especially now, in a time of global fiscal constraint, when we must make every development dollar count.

So UNICEF is intensifying all our efforts, in every country, to reach the hardest to reach, most isolated communities.  This approach, in turn, is not only consistent with, but a vital element in our immunization efforts – because it is in those areas that the battles against polio, measles and other diseases will be won or lost. 

This was certainly true in the winning struggle against smallpox, where outbreaks of the virus needed to be contained, wherever they occurred.

In an 1806 letter to Dr. Edward Jenner, the English scientist who pioneered the first smallpox inoculations, President Thomas Jefferson wrote, “Medicine has never before produced any single improvement of such utility … You have erased from the calendar of human afflictions one of its greatest.”

 Not quite, of course.  It took 171 more years to erase smallpox from the earth – and a global effort unprecedented in scope and single-mindedness of purpose.  This stunning achievement took more than the miraculous discovery of the immunizing properties of cowpox.  

It took more than learning how best to reproduce the virus and mass-produce a vaccine, though this was obviously essential.

It took more than being able to transport the vaccine on a massive scale – in itself a significant achievement. 

And it took more than an international coalition dedicated to defeating smallpox – although that was a critical factor.  It took an international consensus – a collective willingness to wage battle in the last places on earth that smallpox continued to strike. 

The poorest places with the weakest health care systems.  The most isolated communities.  The countries torn by conflict and prone to natural disasters.  In fact, Ethiopia and Somalia – the very places where drought and famine rage today – were the last smallpox endemic countries in the world.  Disease flourishes where development efforts do not reach.

These were difficult, sometimes dangerous undertakings – and they took significant ingenuity by health workers to chase the virus.  But they persisted until they had reached every country.  Every community.  Every adult.  And every child.  Poor or rich.  Rural or urban.  Girl or boy. 

Reaching Smallpox Zero created enormous ripple effects, galvanizing even greater action – and a new understanding of how to wage war against preventable diseases.  A new sense of the possibilities for progress. 
 The late 1970s and 1980s witnessed the birth of new global campaigns to achieve universal childhood immunization.  The Expanded Program on Immunizations, the Universal Childhood Immunization Initiative, and the Global Polio Eradication Initiative were all planned or launched during this period – all committed to reaching the greatest number of children possible.

Driven on by visionaries like my friend and predecessor at UNICEF, Jim Grant, the result was a revolution in child health.  The statistics of their success have not lost their ability to impress.

In 1980, only around 20% of all children received routine vaccinations – as measured by 3 doses of DPT.  Most lived in wealthy countries or the wealthiest households in their societies, while the diseases the vaccines prevented raged on in developing nations.  

By 1990, that number had nearly quadrupled – with almost 80% of all children receiving DPT3, saving millions of lives and billions of dollars. 

But having achieved this, our progress began to slow.  We declared victory too soon.  For 20 years later, we have increased our coverage only by a few percentage points.  We are still reaching only around four out of five children.

But what of the fifth child, the child we don’t reach?  

The child who is likely to be living in one of the world’s poorest countries and the most isolated communities. 

The child who is already deprived of so many basic needs, and who is so much more vulnerable to disease as a result. 

The child who has least access to treatment when ill, so is most in need of preventive care. 

The child who is so much more likely than children in wealthier communities to die before reaching her fifth birthday.

Today, 63 countries have not achieved 90% DPT3 – missing an estimated 17 million children.   Globally, we're missing nearly 20 million children.

We cannot rest until we reach these children – in time to prevent the deaths of the nearly two million children who die every year for simple want of a simple vaccine.  Two million every year.

So we have a lot of work to do – and very good reasons to be doing it.  

First and foremost, we must do it because it is the right thing to do.  Every child has a fundamental right to survive, to thrive and to grow.  It should enrage us all that something as relatively inexpensive, easy to deliver and effective as routine vaccination is still not reaching the places where it can do the most good, and save the most children.

But we also must do it because investing in immunization is highly cost-effective.  In fact, vaccination is one of the best buys in public health, providing an enormous return on investment, however it is measured – in terms of deaths averted, fewer illnesses, or lower health costs. 

And the value of the investment goes well beyond public health – yielding significant economic and social benefits and increasing the future strength of societies.

Poor families which are saved by a vaccine from the struggle to pay for the care of a sick child can better afford to buy more nourishing food, or to provide their children with basic health care or an education.  Healthier children do better in school and can increase their future earning potential.  Governments can make better use of critical resources, better serving all their citizens. 

As UN Secretary-General Ban Ki-moon recently said, there can be no sustainable development unless there is equitable development. 

So, the focus of your meeting is not only a tremendous way to save lives; it is a key determinant of global progress.   And while it is true that we have been on a plateau of coverage in routine immunization, progress is not only necessary, it is possible.

Just look at the progress we have made toward defeating diseases like measles.  Through immunization, measles deaths dropped from 733,000 in 2000 to 164,000 in 2008 – a nearly 80% reduction. 

During the same period, deaths from maternal and neonatal tetanus – a major threat to mothers and babies in the developing world – dropped from 200,000 to 59,000.

Or consider polio, a disease which threatened millions of children and whose cost to societies was enormous.   The number of polio cases reported annually has decreased by over 99% – from 350,000 in 1988 to around 1,300 cases last year.  And to finish the job – as we must – we need to focus more effort on reaching the few places on earth where polio strikes.
Now, having come so far, on so many fronts, how do we accelerate progress on routine immunization once again?  How do we reach the next goal, 90% coverage – and ultimately all children?   Let me offer just a few thoughts.

First, we need to increase our efforts to reach the poorest areas.  For as the history of immunization makes clear, no immunization program – indeed, no development program – can succeed unless we carry the battle to those at greatest risk and in greatest need.  And new vaccines can prevent many of the deaths caused by rotavirus diarrhea and pneumococcus disease – making it more important than ever that we reach the places where they can have the greatest impact.

Among other things, this means we need better analyses of who and where the unreached children are, to help governments and all of us better target our efforts … and to overcome the barriers to progress in these communities.

Second, we need to strengthen the immunization logistics system – and the cold chain that enables us to carry vaccines to isolated and poor communities with little or no access to traditional health facilities.

The cold chain is a major feat of data management, stock control, and storage and transportation systems – which can include everything from high-tech solar-powered refrigerators to transporting vaccine on donkeys to reach a mountain village.  It is supported by personnel all over the world – the people responsible for making sure that those billions of doses of vaccines reach the millions of children who need them … in Afghanistan … in Pakistan … in Somalia … in conflicts and humanitarian emergencies.   They are unsung heroes of the immunization movement.

As the world’s largest procurer of vaccines – around two and a half billion doses every year – UNICEF plays a large role in maintaining the logistics system and cold chain, a job we share with our partners at the World Health Organization, other agencies and especially, of course, governments.  We project that rolling out new vaccines against rotavirus and pneumococcal disease will put greater pressure on the system, requiring more storage capacity and a better cold chain.

In fact, we estimate that to roll out these new vaccines, we will need to triple cold chain capacity over the next five years.  If we want to save as many lives as possible from these killer diseases, it is an investment we must not fail to make. 

We also need to do a better job keeping enough vaccine in the pipeline.  To be able to get the right vaccine to the right place at the right time, we need to do a better job at the country level to assess how much vaccine is on hand.  We also need to create red flag warning systems to avoid “stock outs” that undercut our ability to act quickly and flexibly when we need to.

Third, we must continue to build a healthy vaccine market.  A market that provides the poorest nations with the lowest prices … that better matches supply and demand and assures greater supply security … that encourages new suppliers and further increases competition … a market that spurs even greater innovation, helping to develop the vaccines of tomorrow.  

That is a tall order, of course, and a complex one, involving many parties – and interests that have sometimes been at odds.  But we already have made significant progress, thanks in large part to the efforts of the GAVI Alliance, the Global Polio Eradication Initiative, the Bill and Melinda Gates Foundation, and other partners. 
Our recent effort to bring down the price of polio vaccine is a good example. 

On behalf of governments and other organizations, UNICEF procures millions of doses of polio vaccine every year through tender offers to drug manufacturers.  To strengthen our recent bid, the Bill and Melinda Gates Foundation provided a guarantee that enabled UNICEF to place a firm order without having the final funds in hand.  Manufacturers were able to plan their production needs based on real rather than anticipated demand, which in turn enabled UNICEF to negotiate a lower price for the vaccine, saving the Global Polio Eradication Initiative $60 million.

Earlier this year, GAVI announced it had achieved similar commitments from manufacturers to produce the rotavirus vaccine.  A major manufacturer has announced that it would provide the vaccine to GAVI through UNICEF at $2.50 per dose – a 67% reduction. 

This is a very big win, perhaps saving GAVI as much as $500 million dollars over the next 9 years… and potentially contributing to saving the lives of millions of children every year.

And never forget that every dollar saved is a dollar a developing country could spend on buying more vaccines, to reach more children.

Another remarkable example of how we are shaping the market to meet our immunization goals: GAVI set funds aside to guarantee vaccine manufacturers a pre-agreed price for the pneumococcal vaccine – even before it was fully developed.  Without this Advance Market Commitment, there would have been too much uncertainty for manufacturers to develop this remarkably promising new vaccine.

We need to build on these efforts – and we will.   Because a stronger and more competitive market can also be a far more equitable one, enabling poor countries to protect their children with vaccines as wealthy nations do.

A more competitive market is also a more transparent market.  As you may know, earlier this year, with the strong support of the GAVI Alliance and others, UNICEF made public the prices we pay different suppliers for vaccines.  This helps all of us, and especially governments, to make more informed decisions in negotiations with suppliers. 

Indeed, helping governments to become more self-sufficient in financing their immunization programs is a big part of this endeavor.  This is especially important for middle-income countries with large disease burdens which do not qualify for support from GAVI, but which must preserve their gains in immunization … or risk set backs.

Fourth, it is not enough to bring vaccine prices down or to build healthy markets; we must encourage governments to step up their own efforts and make immunization a national priority.

This is absolutely essential. 

For hard won gains can easily be lost if governments lose focus on immunization programs.  We have seen this in countries like Angola, which had virtually eliminated polio.  But because of problems typical in a post-conflict country, polio campaigns waned and polio returned.  Angola has since renewed its commitment to achieve eradication.

And it goes beyond sustained investments in vaccines and immunization campaigns– it requires a deeper effort to invest communities in the success of those campaigns.

That is why the fifth challenge is working to build demand. 

Many of us have likely regarded the chief barriers to progress in immunization as supply-side problems.  But the UNICEF equity study I mentioned earlier made clear that some of the biggest bottlenecks originate on the demand side.  On the inability of poor people to reach or pay for the medical supplies that could save their children’s lives.

In some of the places we most need to reach, it can take hours, even days of walking to reach the nearest health facility.  Many families cannot make the journey.  Not because they do not want the vaccines.  But because they simply cannot afford to take that time away from harvesting crops, or getting water, or caring for other children. 

Sometimes transportation is available, making it possible for families to go – except the cost is prohibitively high – especially for people trying to survive on $2 a day.

And sometimes, fear, misinformation, even customs, can make communities wary of vaccines altogether.  We saw this recently in Northern Nigeria, where rumors that vaccines caused sterility seriously undermined the government’s immunization campaigns.  

So we need to be sensitive and creative in adapting immunization systems to meet the needs and cultural observances of these communities and families. 

New financial incentives can encourage more health workers to go to remote villages to immunize children.  Not just once, but several times a year. 

We also need to train more people within the community to help with vaccination campaigns.  This is not only because of personnel shortages, but also because it can help overcome cultural barriers. 

The Lady Health Workers program in Pakistan is a good example.  In many rural communities women and girls cannot be examined or treated by male health workers.  But local women can help one another.  So if you train these women as health workers, you can greatly increase health services for women and girls. 

Or, to return to the situation I just described in Nigeria, we overcame barriers of misinformation and mistrust by convincing village heads and Imams that vaccination is not only beneficial.  Not only safe.  But the right of every community and every child.  For the people can be their own most powerful advocates.  

The sixth challenge is better leveraging the power of immunization – by better integrating vaccination with other life-sustaining interventions.  

In fact, immunization programs are at the leading edge of providing other lifesaving interventions to the communities in greatest need.  For if we can reach these children with vaccines, we can also reach them with Vitamin A, iodized salt and other micronutrients to prevent stunting … and bed nets to prevent malaria.  

Combined with improved sanitation and healthy practices like hand washing, wider distribution of new vaccines against rotavirus and pneumococcal disease, which combat the biggest child killers – diarrhea and pneumonia – can radically reduce child mortality. 
This is especially important in humanitarian crises.

In the Horn of Africa right now, addressing severe acute malnutrition is our top priority – for 300,000 children are at imminent risk of starving to death.  But outbreaks of deadly diseases also pose enormous threats, especially when children are already so much more vulnerable.  Hence the need for additional interventions, including immunization.

Finally, universal immunization depends on new innovation – and the development of new vaccines.
To meet this challenge we need to engage with the pharmaceutical companies more than ever – and to develop the market for new products.  

The new pneumococcus and rotavirus vaccines are now becoming available to developing countries.  Our expectations for these new vaccines are very high, measuring in millions of lives saved.  Other new vaccines are also cause for cautious optimism.  HPV vaccine will prevent countless women from dying of cervical cancer.  As many of you will know, a malaria vaccine is in an advanced trial stage, and may be licensed by 2013 or 2014.  And the future may yet hold promise for vaccines to prevent transmission of HIV.

All of these vaccines have the potential to bring us that much closer to a world where millions of children no longer die from causes we could prevent, simply because of who they are and where they were born.   We must reach those children to prevail.

We know how to do this.  We can do this.  And because we can, we must.

So let me conclude my formal remarks by posing a question. 

Jim Grant was fond of quoting Arnold Toynbee, who said that the 20th century would be remembered as one “in which human society dared to think of the welfare of the human race as a practical objective.”  What will these first years of the 21st Century be remembered for?  

They can be remembered for eradicating polio.

They can be remembered for controlling measles …for preventing deadly diseases caused by rotavirus and pneumococcal disease … and other diseases that threaten the lives of our children and undermine the strength of our societies.

They can be remembered … for achieving truly universal – and truly equitable – immunization.

But this is up to us.  

Having come so far, we cannot afford to see our progress rest on this plateau – or watch our hard won gains slip away.  Having scaled this much of the mountain, we must reach the peak. 

Let’s be remembered for that.

Thank you.




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