In his latest annual letter, Bill Gates warned of the imminent threat of a deadly pandemic to the global community. Yet, while his message also lauds the accomplishments of vaccine coverage, he has consistently lacked the emphasis on a crucial element of global health security: If we truly want to prepare for the next pandemic we need to invest in health systems, not just vaccine development.
Gates is not alone. Vaccines as the solution to major global health problems is emerging as a theme for global health in 2017. A new multi-million dollar initiative, the Coalition for Epidemic Preparedness and Innovation (CEPI), is an admirable solution to build an arsenal of vaccines against diseases that may not turn a profit but would protect thousands of lives. In a global health funding environment with an uncertain future due to President Trump’s plans for budgetary cuts, this could be a wise investment. However, pandemics will not be beaten without the participation of the people most affected. And the critical component currently being overlooked is the value of resourcing health systems in countries most under threat.
The World Health Organization says the role of the health system is to improve the health of the population through organizations, people and actions that promote, maintain or restore health. The three countries ravaged by the most recent Ebola outbreak did not have such health systems in place. Ebola showed us that fragile health systems are the catalyst for uncontrollable outbreaks. It has been stated time and time again that it was not Ebola—a virulent but not very infectious disease, but the fragility of the health systems that led to the disastrous outcomes. An example of this is how Nigeria avoided what could have been a colossal disaster by, among other things, utilizing the existing coherent health system built upon polio eradication efforts. This system mobilized epidemiologists and health workers who were already trained and familiar to the community. Their heroic and quick efforts quelled the dangerous disease just three months after it touched Nigerian soil compared to 14 months in Liberia and 18 months in Sierra Leone.
Vaccines work. Full stop. But vaccines need effective systems to get to all who need them.
The issue of efficacy versus effectiveness is an important discussion in the world of vaccine development. Efficacy looks at the strength of a vaccine and can be calculated in a study setting that measures the percentage of people vaccinated who do not get a disease versus the number of people who were not vaccinated. Effectiveness, on the other hand, looks at how the vaccine holds up in the real world. Potential issues that could hinder the vaccine’s ability to protect a population range from individual biological factors to more systemic and practical challenges. These include having enough trained health workers to give the vaccine, or having constant cooled storage area to keep vaccines stable in sweltering tropical or desert climates.
Another major barrier to individuals getting vaccinated is the distance between communities and health care providers. Even though half of the world lives in rural areas, the health workforce is unequally skewed to urban areas—meaning rural and many times, the poorest people cannot access nurses and doctors when they need to.
A well-planned health system includes thoughtful and customized solutions to these problems. Vaccines are an intervention that can protect children by strengthening and extending existing immunization and other health structures. Mr. Gates and other donor communities would do well to encourage the normalization of seeking health care by supporting primary healthcare services that allow for regular contact with difficult to reach communities. Often this will require country-specific innovative solutions like the Ethiopia’s health extension program and mobile HIV testing in South Africa.
So why do we not invest in health systems? Why do we continue to focus on vaccines and treatment and really cool malaria-zapping lasers? Perhaps the issue seems too complex or too expensive.
Providing healthcare to everyone is certainly complex, but it’s a familiar complexity. This issue should resonate with every Brit who is watching the struggle between NHS and Junior Doctors and with Americans who want reassurance that if they get sick they will not endure crushing medical debt.
Investing in health systems requires a true desire to shift the donor-recipient narrative, because it ultimately means talking about sustainable and locally managed national systems. This is what we want right? There is strong evidence that investing in the health systems of Guinea, Liberia, and Sierra Leone would have cost almost a third less than the £2.8 billion (US$ 34.7 billion) spent on foreign aid and response measures.
Bill Gates and other donors’ investment in CEPI is a much-awaited action towards preventing the next pandemic. This is only part of the story. To truly prepare for the next pandemic, we need to invest in innovation AND effective and resilient health systems. This is not a new message, but it is a constantly overlooked one. We cannot afford any longer to keep talking about the need to strengthen health systems—we must invest more in health systems in low-income countries now.
Image: Ebola public health wall message. Credit: Tom Mooney/London School of Hygiene & Tropical Medicine