The reality of vaccinating Africa

Last Modified: 19 Nov 2007
By: Jonathan Miller

Tens of thousands of children die every year from pneumonia. Can a new vaccine scheme save lives?

Its been hailed a ground-breaking scheme that will save millions of lives. A £750m pledge from wealthy governments, including ours, to fund the development of a vaccine for pneumococcal pneumonia - Africas biggest child-killer.

Called an "Advance Market Commitment", the scheme's a pet project of Gordon Brown. Drug companies are guaranteed future profits in return for developing vaccines for use in the third world.

But there are concerns that the money will simply end up boosting the coffers of those companies rather than funding treatments.

At a small farmstead deep in the bush, an entire community has gathered to bid a final farewell to Bernard, a toddler.

Bernard Steven was an AIDS orphan but he didnt die from AIDS; what killed him was a vicious and virulent strain of pneumonia.

Living miles from a main road, Bernard didnt make it to hospital in time.

You might not have heard of it, but pneumococcal pneumonia is Africa's biggest child killer.

Before penecillin came along 80 years ago, pneumococcal pneumonia was a disease more fatal than even the dreaded ebola virus. Thanks to anti-biotics, though, infant-mortality rates have plummeted.

The multi-billion dollar question now is whether a pneumococcal vaccine will be the silver bullet.

Scientists believe thats possible. The problem is how to pay for it - for silver bullets dont come cheap.

The multi-billion dollar question now is whether a pneumococcal vaccine will be the silver bullet.

Gordon Brown believes he has the answer. Innovations in finance will fund innovations in medicine, he says, now we can triumph over ancient scourges.

He's won praise on the world stage for his vision of funding dream vaccines which he believes will save millions of children who needlessly die in developing countries from diseases the rich world has long ago banished.

First on his hit-list: pneumococcal pneumonia. Prime Minister Brown has summoned into existence what he calls a great coalition of conscience in pursuit of a vaccine that could have saved Bernard Stevens life.

And how is this done? Through what's actually a new twist on those old public-private partnerships, a PPP for the Third World this time, rebranded an Advance Market Commitment, or AMC for short.

"Pneumonia as we have heard is the major infectious cause of child mortality worldwide. With this one initiative and 1.5 billion dollars, we are able to say over the course of the next 25 years the lives of 5 million children will be saved," says Brown.

And who could knock that as a dream? Until now, anti-biotics like penecillin have been the only means to treat pneumococcal pneumonia, a disease wrought of poverty.

Committing to the poor world

I've come to Malawi, one of the poorest countries in Africa, where a vaccine might indeed save tens of thousands of children each year.

Through Gordon Browns AMC, Britains already pledged £250m. And, at the prime minister's urging, Italy, Canada, Norway and Russia have also joined his coalition of conscience.

The idea is that the vaccine will be produced for the poor world, with the rich world committing the money up front.

But there's a growing number of sceptics out there who claim that the lion's share of that cash injection won't end up here in Africa, but in the corporate coffers of big pharmaceutical companies.

Companies like Britain's GlaxoSmithKline, and US drugs giant Wyeth who lead the field in pneumococcal vaccine development.

Professor Donald W Light from the Centre for Bioethics, Princeton University, says: "Yes, the current so-called AMC contract calls for a price where 80 per cent of the 1.5 billion donated will not go to doses, to immunise infants and little children and save them from serious disease and death but will go to profits of GSK and Wyeth. And I think thats indefensible."

Dr Neil French, Directorof Karonga Prevention Study, conducts field trials in Malawi to test whether pneumococcal vaccines are going to be effective in a part of the world where HIV is rife.

"This is the pneumococcus," he says, "Which is the bacteria that is responsible for the majority of the pneumonia respiratory disease that we see in Malawi."

He's been studying pneumococcal disease most of his professional life. And when it comes to Malawi, he says, vaccine development is just not that simple.

We know from several studies that the vaccine works. What we don't fully understand are the limitations of the vaccine.

Unlike other diseases for which there are vaccines, there are many different strains of pneumococcal disease. The five strains most prevalent in Europe and America are not those most common here. Which is why the pneumococcal vaccine currently used in Europe and America doesnt work so well in Africa.

Visiting time

We visited Karonga Hospital, in Malawi's far north. There are a quarter of a million people in this district and two doctors - who take weekends off.

It's Sunday and the paedeatric wards are full; many of these children have pneumococcal pneumonia. And there's a new arrival. His name's Hastings and it's taken his mum five days to get him here. It's touch and go.

This little boy is one year old and already, in his short life, he has contracted pneumonia twice. His twin brother died about five months ago from pneumonia. His mother has brought him here and is relieved to have made it to the hospital because they live in a far-outlying district.

When I asked her whether she has seen many such cases of pneumonia in her district, she said many. There's been no regular doctor on this ward for a year. Lizzie Mzumara, Karongas most senior nurse, is a bit of a pneumonia expert; she sees hundreds of cases a year.

She told us: "It's the biggest problem, pneumonia in this district. Some may have other conditions like severe anaemia, malnutrition... These other conditions complicate pneumonia treatment. Many children also die as a result of misdiagnosis by under-trained rural health workers, and only one in 10 ever makes it to hospital. But those who do tend to survive.

"For the month of August we registered 44 patients and out of 44 patients, 43 we have cured."

Startling evidence, leafing through her pneumonia admissions records, of the effectiveness of cheap antibiotics; virtually every child who makes it in here is discharged within days, right as rain.

Just a few cents

Professor Kim Mulholland of the London School of Hygiene and Tropical Medicine says: "Most cases of pneumonia can be treated with penicillin which costs a few cents.

"The cases admitted to hospital may require two injectible antibiotics but they can also be provided relatively cheaply. And as the vaccines that we are talking about, the new vaccines, particularly pneumonia vaccine, come into use, we have to compare the cost of the vaccine against the cost of other strategies, and frankly those vaccines are quite expensive.

"A vaccine though offers a one-off solution in a country where nine out of 10 people don't get to hospital fast enough, where the health infrastructure's crumbling, where sometimes there aren't any anti-biotics - or even nurses.

"But the cost of the vaccines important because the cheaper it is, the more childrens lives it will save."

The Advance Market Commitment promises a cut-price vaccine by guaranteeing the big pharmaceutical companies big enough sales. But even at the 90 per cent discount cited in AMC documents, it's currently estimated one dose will cost between five and seven US dollars.

It'll still be the most expensive vaccine in the developing world. And, it's claimed, the AMC will still be paying the drugs companies far more than it'll cost them to produce it.

"The issue I am raising is shouldn't they not profit from the poor. And what people dont realise is that these prices involve a 5-700 per cent mark-up over costs as far as I can tell. I think its possible as has happened with meningitis vaccine, to get the cost down below a dollar, to 75 or 50 cents a dose."

Donald Light is not a lone voice in the wilderness. Leading Indian drug manufacturer Dr Suresh Jadhav of the The Serum Institute also thinks the vaccine could be made far cheaper in places like India.

Dr Jadhav said: "People in the West feel that if they make something for a dollar and cannot sell it for more than $20, it's a non-viable project.

"Whereas you go to Southeast Asia, those people will feel if you can make something for a dollar and sell for $2, you are 100 per cent profit. So it's more philosophical rather than business."

There are also concerns about what will happen ten years from now, when the AMC vaccine fund runs dry. Unless poor countries get more help, it's very unlikely they will be able to afford to keep vaccinating children.

Critics say that even with a 90 per cent reduction in price there's still plenty of profit to be made.

Baroness Shriti Vadera is International Development Minister and Brown's former treasury adviser, brains behind several pubic-private partnerships one of the architects of the pneumocaccal AMC.

I put to her that at the five to seven dollars price, cited in the AMC documents, parmaceutical companies would still be reaping big profits.

"We have not yet signed the agreement and we will sign the agreement if we believe it to be value for money," she told us, "So the current discussions and negotiations are suggesting a price within that range."

I asked her if that range represents a considerable mark-up for the drugs companies.

"The price range indicates a 90 per cent decrease in the current price of that vaccination that is available in the West but is not effective for Africa," she said.

"This would represent the steepest drop in the the price of a vaccination in its first year of production ever in the history of vaccinations."

But critics say that even with a 90 per cent reduction in price there's still plenty of profit to be made.

GlaxoSmithKline has its own concerns. As questions remain about the price of the vaccine, there are, it turns out, still no guarantees about volume of sales to justify its investment and to keep GSK shareholders happy.

GlaxoSmithKline's Dr Kate Taylor said: "Actually no price has been set. And nor is it appropriate to talk about price, before there are volume commitments and companies can have the confidence to talk to their shareholders and say we should invest in capacity to produce vaccines and that the international community is really serious about childhood vaccination."

Channel 4 News also approached Wyeth for a comment, it said that it commended the launch of the AMC and said that it was "working closely with ... the international community to help ensure that ... vulnerable populations have access to [its] ... pneumococcal ... vaccines through an affordable and sustainable plan."

The witch doctor

The concerns of the big pharmaceutical companies are a world away from Karonga South, in the absence of doctors - let alone vaccines - worried parents take their sick children to the local witch doctor.

Meet Dr Fumu Zapasi Mangho, local headmaster and self-styled King of the Underworld.

People here take their witch doctors very seriously.

How important do you think it is for the people of malawi to have a traditional doctor like you? We asked the doctor.

"It was not their hope, but God just gave them me to assist them."

Dr Fuma Zapasi sees a lot pneumonia cases and believes he really does cure them. Elsewhere, opinions are divided as to the efficaciousness of the doctor's prescriptions.

Death is so much more a part of life in Africa than it is in the rich world and advances in medical science now render many of those deaths needless.

If two-year-old Bernard had been born in Britain, he'd still be alive. Here in Africa, they live with the daily injustice of this deadly lottery.

When a child dies, there are so many questions left hanging. The pneumococcal vaccine plan offers one answer. The people burying Bernard just want something done.