The strategy of mass vaccinations is a very effective way, to safe lives. And Gavi has done a lot, to make these vaccination-strategys a success. Does this top down approach lead to stronger health care systems in weak countries too? I ask because what we saw in the Ebola-crisis in West-Africa.
That is a complicated issue. But it is the right question. And the answer is: Yes! Of course there is a whole other school of thought that says you should mainly invest in the systems. But they are very hard to measure, and my impression is, they do not work very well. Gavi does not just invest in vaccines. It invests 15 to 20 percent of the funding in cash based programmes. In the West-African countries Liberia, Sierra Leone and Guinea Gavi invested 53 million dollars into the health systems. The challenges in post-war countries are big. But things were upswing. Child mortality was falling, immunisation covering was going up, supplys in health posts were going up. But they were not resilient enough and collapsed. And they had no experience with Ebola in the past. Uganda had four outbreaks of Ebola but were able to build up a system how to control and contain it in a very poor country without continuing funding.
The Ebola outbreaks in Uganda, as in the Democratic Republic of Kongo, happened in very far out rural areas. Do you think, Uganda could have handled Ebola in the capital Kampala too?
I think so. If you find out early it does not really matter, where it is. Important is to have the ability to step in decisively, quickly and be able to do the follow up. Still that is no guarantee you always can miss somebody, who can not be found. But Nigeria was successful too. In Nigeria the Polio-system, that was put in place, a vertical system, was used for the emergency measures. What is important to keep in mind, is, that of all interventions immunisation is the intervention that reaches more children than any other. It has in fact enabled outreach in areas, that have been difficult to get to, dangerous, controversial or stigmatized. In that sense immunisation is the base of the pyramid. With the investment into immunisation come the village health workers, the local facilities. Not always this leads to health posts that can provide more services than immunisation. But it is a contact to health workers it is where parents ask other questions, it is an initial building of systems. Gavi though has no own people on the ground. Zero. We work to help empower countries to build up their own systems to be able to do this. We use Unicef and other organisations to provide technical assistance. But it is all about the work with the countries. And not only global immunisation rates go up. The capacity to manage a health system, or supply chains – Germany helps a lot with that – is going up too. All that can be used for other things too.
"We try to strengthen health systems"
So you try to use existing systems but sometimes you have to build up new systems. How often does that happen that there is no structure to use?
I you want to reach adolescent girls there is no system to use. So when you go out of the ordinary you face that situation and start from scratch. If you only add in a vaccine against pneumonia into an existing immunisation system for children you can use that. In general we try to use the existing structures and try to find ways to put that into the health budgets of the countries. On the long run we try to build up strong systems for the future which can make use of an Ebola vaccine as soon as it is there when needed.
How do you work with the countries?
Take for example Kenya. They want to vaccinate girls against Humane Papillom Virus (HPV), a virus that causes cervical cancer. They said: We have a good system. We do not need a demonstration project. We know how to do it. It turned out, they did not know, how many girls went to school and how to reach them in school. What happened was that in a demonstration project, they established how to find and reach girls in school. That is a lesson that will spread to other programmes and systems. Cervical cancer is one of the biggest killer for women in the world. But it is not only that, it is a age group that is so important and should learn more about their health.
At which age are they immunized?
Between nine and ten. At places it might be a bit early for sex education, and the early age has to do with the very early engagement of girls. But on things like a safe motherhood, on basic hygiene and sanitation, violence against women are topics, which are brought up in some of the HPV-programmes.
The data about cervical cancer: how accurate is it? Do you have those numbers because it is one of the view cancers that is diagnosed in developing countries, or is it, because do many women develop the disease?
The data for cancer is not so bad. From places where autopsies are done you can calculate the numbers in other places without good data too. But why is it such a common problem in Africa? It has to do with HIV, because this escalates the transmission of HPV and the risk to develop the cancer with an already weakened immune system. We know that the virus has spread as part of the sexual revolution. And there is no screening. Most women in developing countries do not get one health screening in their life. If you had early cancer, there is no diagnosis, and if you develop the disease there will be no treatment available. 90 percent of the cancer deaths occurring are occurring in developing countries, it is terrible. This is an intervention that works today and can save lives.
Syringes are "a great example of disasters"
One of the problems of immunisation are syringes. How do you deal with the hygiene problems that are everywhere? Are one-time-syringes really only used one time?
A great question. It used to be a big problem and we have great examples of disasters. One example is hepathitis in Egypt. You have got five to seven percent national infection rate because of the health ministry giving injections for schistosomiasis with contaminated needles. Gavi began a programme to do two things; to bundle syringes with vaccines and to bring order disables syringes in. They can not easily be reused. Now in all of the 73 Gavi-countries they are in use now. Injection safety had a high priority. Especially in Africa where people love injections. It might have to do with some campaigns that were seen as miraculous. For example against a variation of syphilis of the skin. People got horrible deformed and after one injection it just disappeared. So people thought this is powerful medicine.
"There is a row going on about Cholera vaccines"
How do you think about the Cholera vaccines? One now was used in South Sudan and before Haiti was a candidate.
It is not top of mind in Gavi. But there are many places with endemic cholera, from Louisiana to many places in Africa. So in Gavi this was not a big debate. And there is a row in the health community if the use of a Cholera vaccine might not slow advances in sanitation which is what it is all about. It has been a huge battle. A stupid battle. Because a long term solution of course is what you want. But in an acute epidemic situation you still might want to use what you have. The second part of the controversy is how to deal with endemic Cholera. Do you use it for heath workers only? Do you do ring vaccinations? Or give it out to everybody? We do not know the answer to that. There should be done some monitoring studies for example in Haiti where Cholera went to epidemic to endemic.