KEYNOTE ADDRESS, GLOBAL IMMUNIZATION MEETING, KIGALI, RWANDA, 26 JUNE 2018

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KEYNOTE ADDRESS, GLOBAL IMMUNIZATION MEETING, KIGALI, RWANDA, 26 JUNE 2018

Professor Rees, the keynote speaker, chose for her topic “Looking from the Outside In.” Where do vaccines rest within our global world? The good news is that both total fertility rate and child mortality have declined, in synchrony, since the 1950s. Child spacing contributed to achievement of MDG4. Life expectancy has risen in all regions, though AFRO lags the other regions. Vaccination coverage has increased since the ‘80s, but less quickly in recent years.

The political context affects EPI, notably recent violence in Addis Ababa and Harare. Nationalism has risen in Europe, the US, Russia, and India. Nationalism is the flavor of the day. It is not, however, the best way to go.

Trade wars will affect all of us, especially poor countries. Rejection of migrants in Europe and the US is a retrograde tendency.

What has happened in recent centuries?

• World population has risen.
• Urbanization has taken off.
• Transportation has mushroomed.
• Water use has risen in unsustainable ways.
• Telecommunications have taken off.
• Real GDP has risen, both in OECD and developing countries.
• Income gaps have widened, with most increments going to the wealthiest 1 percent.

Africa is seeing a demographic transition, with an adolescent bulge. But is this a demographic threat if we have no jobs for young people?

The IOM reports that 130 million are migrants of one kind or another. We had >100 conflicts in 2015. The Yemen hosts a proxy war between Saudi Arabia and Iran. Refugee populations are rising, especially Syrians and South Sudanese.

Most displaced persons go into neighboring countries, not into OECD countries. By 2030, half the world’s poor people will live in fragile countries.

Eco-migration will follow in the wake of climate change. Between 2030 and 2050, we will see additional deaths from heat stroke, starvation, and other causes linked to climate change (reference: “Climate Change and Health,” World Bank).

From 1975 onwards, we have seen the emergence of HIV, Ebola, new flu strains, SARS, MERS, and Zika, among others.

WHO restructured after the Ebola outbreaks of 2014, with a new Health Emergencies Programme. We have also mapped the global distribution of pandemic preparedness. The countries least ready to respond are the poorest ones. Disasters affect poor people more than nonpoor people. [graphic]

Urbanization moves apace. It is driven by cities in emerging markets. By 2050, Africa will grow to be 50 percent urban. We are seeing more poorly planned megacities of >10 million people.

Global ambient air pollution is growing, notably in India and China (source: Greenpeace). Deaths from air pollution are commoner in developing than in developed countries.

An estimated 40 percent of under vaccinated children were in urban areas in 2016. Kampala has 3 million people by day and 1 million by night.

Global health funding is at risk during the current period of polio transition and GAVI graduation. Polio funding will decline once global eradication is certified, about 2021. Funding for GPEI supports broader vaccination.

External funding for health has leveled off in recent years, especially since 2010. Since 2013, there has been an absolute drop. Non-communicable diseases get little funding. HIV funding first rose, then fell. Talk of the “AIDS free generation” has led to complacency.

Modeling has been done on possible impacts of continuing declines in HIV funding. Let’s not take our foot off the pedal.

UHC, universal health coverage, is within reach. [graphic on per capita health spending by country]. South Africa spends a lot on health, but 80 percent of our spending is on the 16 percent of the population who get services in the private sector. In poor countries, half of all health expenditures are paid out of pocket. This is not the case in richer countries.

Reference: WHO, “Tracking Universal Health Coverage: 2017 Global Monitoring Report.”

Premature lives lost are higher in developing countries, or in those which fail to regulate tobacco.

Lower middle income countries see non-communicable diseases as a major cause of death. This is even more pronounced in upper middle income countries and wealthy countries.

Key reference: Report of the WHO Independent High Level Commission on NCDS, The Lancet, 2018

Dementia and suicide are among the leading causes of death in OECD countries. Oncology drugs are getting more and more costly. However, additional clinical benefit declines with additional expenditure.

Antimicrobial resistance is a growing threat in all countries.

Gender violence drives HIV, and also drives child neglect.

“The Global Health 50/50 Report,” 2018, looks at gender issues.

Take home lessons for immunization:

• Donor funding priorities are changing.
• Beware complacency, the false view that the immunization job is done.
• Continue to explore new funding modes.
• Domestic financing is essential for sustainability.
• National ownership and political will are needed, as is smart taxation.
• Accountability needed at all levels
• Engaging civil society is essential.
• Continue dialogue with manufacturers/private sector to keep vaccine prices and services affordable.
• Integration of services is essential.
• New GVAP after 2020

“No man is an island, entire of itself.” – John Donne

“The times, they are a changing.” – Bob Dylan