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FROM BILL GATES'S 2012 ANNUAL LETTER

Saturday, 28th of January 2012 Print

VACCINATION, AIDS AND THE GLOBAL FUND, FAMILY PLANNING -- FIRST GATES VACCINE INNOVATION AWARD GOES TO A. A. HOSSAIN

Full text of the letter in six languages,
http://www.gatesfoundation.org/annual-letter/2012/Pages/home-en.aspx

Vaccines "Because of that money, the poorest infants in the world will start receiving the same vaccines that infants in rich countries receive." - bill gates There are still years of work to be done to introduce the diarrhea and pneumonia vaccines into every country. Moreover, global coverage of basic childhood vaccines is around 80 percent, which is good compared to many other health interventions but leaves one out of five children unprotected. We need to recreate the high-level political focus that this issue received during the 1970s, when dedicated effort brought us from just 20 percent coverage to 80 percent coverage in most countries in just a decade. When I spoke at the World Health Assembly last May, I announced that I was creating the Gates Vaccine Innovation Award. We were pleased to receive 117 nominations encompassing a lot of amazing work. Vaccines are the only high-technology product that needs to be delivered to every single child. To miss zero children, it takes an incredible amount of ingenuity, and that’s why we created the award. Melinda meets with Dr. Asm Amjad Hossain, the recipient of the first Gates Vaccine Innovation Award (Dhaka, Bangladesh, 2012). I am pleased to announce here that the first award will recognize the work of Dr. Asm Amjad Hossain, a district immunization medical officer from Bangladesh. In 2009, Dr. Hossain was assigned to two districts where immunization rates were 67 and 60 percent, respectively. In 2010, they were 85 and 79 percent. These rapid improvements were the result of Dr. Hossain’s innovative approach to running an immunization program. He instituted a process of registering pregnant women with their expected date of delivery, location, and phone number, so vaccinators knew when children were born, where they were, and an easy way to contact their mothers. He provided annual schedules for vaccine sessions to make vaccinators more accountable to the community and had the vaccinators put their phone numbers on the children’s immunization cards, so parents with young children could get in touch with a health worker. These may seem like small innovations, but they show how looking at old problems in new ways can make a profound difference. Improvements like these are spreading to other locations because of the commitment and creativity of Dr. Hossain and many others like him. Delivering lifesaving vaccines takes the dedication of many well-known players like GAVI, the World Health Organization, and UNICEF; government officials; and perhaps most importantly hundreds of thousands of heroes on the frontline like Dr. Hossain. Polio The foundation’s top priority remains helping to complete the eradication of polio, perhaps the best-known vaccine-preventable disease in the world. I spend a lot of my time learning about the disease and being an advocate for doing what it takes to end polio. At the start of 2011, poliovirus was still spreading in three areas: 10 countries in Africa (with viruses that originated primarily in Nigeria), Afghanistan and Pakistan, and India. Now India has reached a huge milestone. The country had only one case in 2011, which was recorded on January 13 in West Bengal. So on January 13, 2012, India celebrated its first year of being polio free. The challenge in India was mind-boggling. It’s hard to imagine how you would design a polio campaign that reached every Indian child. More than a billion people live in the country. Massive numbers of families migrate constantly to find work. One of the largest states, Bihar, is flood-prone. In some cases, the vaccine didn’t work as well as it had in other parts of the world, probably because of malnourishment, diarrhea, and other illnesses. But the government kept raising awareness and improving the quality of its campaigns, even in the toughest locations. The Indian government deserves special credit for this achievement. In 2012 we need to keep India and all the other places that are polio free from getting re-infected. The biggest focus for 2012 will be improving the polio vaccination campaigns in Nigeria, Chad, the Democratic Republic of Congo, Afghanistan, and Pakistan. I recently visited Chad and Nigeria to meet with leaders there, and it’s clear that we have high-level political support. Still, deploying high-quality vaccination teams and educating parents so that every single child is vaccinated will take a lot of work. In Nigeria our biggest problems are low-quality campaigns and the fact that some parents don’t trust that the vaccine is safe. In Pakistan these problems are compounded by the security situation. It will be challenging to continue raising the approximately $1 billion per year it takes to run the global campaign. Last year the United States, the United Kingdom, Australia, Japan, Canada, Norway, Saudi Arabia, the Crown Prince of Abu Dhabi, and Rotary International provided substantial contributions. Rotary continues to be the heart and soul of polio eradication, supporting the program directly while also taking on a larger role in encouraging other donors to give more. A new partner, FC Barcelona, is spreading the message of polio eradication to millions of football fans across the globe. We are continuing to invest in studies about how polio spreads and trying to model where we need to intensify the vaccination campaigns. We are also working on new vaccines. Finding every last poliovirus requires good tools along with trained and motivated workers in every single country. These are enormous obstacles, but the success of the polio eradication program in India and 90 other countries gives me confidence that we can triumph in these final challenging countries and end polio once and for all.

AIDS and the Global Fund The AIDS community has three big goals: Reduce the number of people getting infected. By 2015, the goal is to cut infections to 1 million per year, which would represent a 68 percent drop from the peak a decade ago. Provide drugs for everyone who needs them, so those with AIDS can live longer and more productive lives. Last year, 1.8 million people died of AIDS. Find a cure. Although there are people working toward a cure, it is viewed as so difficult that we can’t count on ever having one. There are many ways to tackle the first goal: reducing infection. These methods can work individually and in combination. One approach is to convince people to avoid risky behavior. Education efforts are important, and they are getting more targeted, but their impact is uncertain. A second approach is male circumcision, which reduces HIV transmission by up to 70 percent. Funding for circumcision is finally being prioritized, since the cost is quite low and the protection is lifelong. Over 1 million men ages 15–49 have been circumcised in 14 Southern and Eastern African countries with large AIDS epidemics, but that is only 5 percent of the total number who could benefit from the procedure. Even in the ancient practice of circumcision, innovation has the potential to make a big difference. The new PrePex and Shang Ring devices simplify the procedure and make surgery unnecessary. The first studies suggest that these devices are both safe and effective. (I will keep this letter G-rated by leaving out the pictures of how the devices work.)

Botswana, Kenya, South Africa, and Tanzania are starting to show leadership by getting the message out to all young men that it is important to get circumcised. Kenya has made the most progress, circumcising 70 percent of eligible men. I will be very disappointed if, by 2015, any fewer than 15 million young men have chosen to protect themselves and their partners by getting circumcised. A third approach to prevention is to come up with an injection or pill or gel that reduces an uninfected person’s chance of becoming infected. The final results of studies of a number of these tools were reported in the last 18 months. In studies where the patients used the tool as they were supposed to, the results were quite good. However, in most studies the levels of usage were low and thus the overall results were disappointing. This has the field thinking hard about how you could motivate better adherence or create a tool that requires less effort from the patient. One example in early development is an injection that lasts 30 to 90 days. I think we will solve the adherence problem, but we are going to have to get medical scientists, social scientists, community representatives, and regulators working together. We have to develop and test overall delivery systems, including communication, support, and incentives, in ways that go beyond what a medical trial alone typically does. A fourth approach, called treatment for prevention, is to give antiretroviral (ARV) drugs to people with AIDS earlier in the course of their disease, greatly reducing the chance that they will infect others. This is already done for pregnant mothers to reduce the chance of infecting their babies during delivery or through breast-feeding. The field has a goal of getting drugs to 90 percent of HIV-positive mothers by 2015, virtually ending mother-to-child transmission. The main problem with treatment for prevention is that most people who are infected with and transmitting HIV don’t know they are infected, so you wouldn’t know to give them drugs. In order to realize the full potential of treatment for prevention, we need to encourage widespread HIV testing, which will require developing a reliable, inexpensive saliva test that can be used privately.

"More than 6.6 million people are alive today because they are taking ARV drugs. Ten years ago it looked as if almost all of these people would die because the drugs were only available in rich countries." - bill gates Twitter Facebook One further approach to prevention is an AIDS vaccine. On this topic, this year’s news is very similar to last year’s. The scientific understanding of the AIDS virus—its shape, how it enters cells, and how we can use antibodies to block it—has advanced more than expected. However, plans for conducting trials of different constructs are still not as aggressive as they should be, given how game-changing a vaccine would be. It is still possible to have a vaccine within 12 years, but it will take some luck and better planning. It is exciting to have so many prevention approaches available, and to be making progress on most of them. Funding continues to be a serious concern, but I am optimistic that the field will develop combined approaches to significantly bring down the rate of infection. Meanwhile, there has also been amazing progress on the second major goal for the AIDS community: scaling up treatment. This is due mostly to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and to a U.S. program called PEPFAR: the United States President’s Emergency Plan for AIDS Relief. More than 6.6 million people are alive today because they are taking ARV drugs. Ten years ago it looked as if almost all of these people would die because the drugs were available only in rich countries. Between 2008 and 2010 the Global Fund gave $8 billion for AIDS (57 percent), malaria (29 percent), and tuberculosis (14 percent). Other than PEPFAR for AIDS, the Global Fund is the biggest donor for all three of these diseases. It provided the money for 230 million bednets, which have been key to the 20 percent decline in malaria deaths over the past decade. It also provided treatment for 8.6 million cases of tuberculosis. I am not doing a section on malaria or TB in this year’s letter, but there has been good progress in both diseases, with the Global Fund being key to this. The Global Fund does a lot to make sure its money is spent efficiently. Given the places where the Global Fund works, it is not surprising that some of the money was diverted for corrupt purposes. However, the Global Fund found these problems itself and changed the way it handled training grants, where most of the problems were. Unfortunately, news of any corruption makes many citizens think the entire program is mismanaged and a huge portion of the money is being wasted. Some of the headlines that talked about two-thirds of specific grants being misdirected fueled this impression. In fact, less than 5 percent of Global Fund money was misused, and with the new procedures in place that percentage will be even lower. Our foundation is the biggest non-government supporter of the Global Fund, committing $650 million over the years because of the incredible impact its spending has. I am confident that this is one of the most effective ways we invest our money every year, and I always urge other funders to join us in getting so much bang for our buck. Between 2011 and 2013, assuming that all donors honor their commitments, the Global Fund will disburse $10 billion. This is a $2 billion increase, but not nearly the $12–$14 billion that is needed and was hoped for. Citizens of donor countries should know about the difference their generosity has made. The cost of keeping a patient on AIDS drugs has been coming down, and it looks like getting it to $300 per patient per year should be achievable. That will mean every $300 that governments invest in the Global Fund will put another person on treatment for a year. Every $300 that’s not forthcoming will represent a person taken off treatment. That’s a very clear choice. I believe that if people understood the choice, they would ask their government to save more lives. Family Planning Melinda has focused a lot of her foundation time on family health issues, including maternal and infant health, nutrition, and family planning. In 2012 and beyond, she will really emphasize family planning—giving women the tools they need to plan how many children they have and when they have them. She will be talking much more about how having the ability to plan changes the lives of women and their families and improves whole societies.

Last year, Melinda met with mothers in Korogocho, a slum outside of Nairobi, Kenya. She was touched by one woman who explained why she wanted to be able to space her births further apart: “I want to bring every good thing to one child before I have another.” One amazing thing is that parents’ desire to bring every good thing to their children can have a huge impact on national economies. Melinda spoke at the World Bank about how developing countries have a chance to benefit from something called the “demographic dividend.” The idea is that as parents bring their family size down, countries can invest more in educating young people. When those young people reach working age, they boost productivity and economic growth. South Korea and Thailand are two recent examples of how countries that understand and capitalize on these principles can rapidly transform their economies. Over the next 40 years, the global population is projected to grow at just .8 percent per year. It just passed 7 billion and will reach 9.3 billion by 2050, according to the United Nations’ medium estimate. However, the populations of most poor countries, which have the hardest time feeding and educating their citizens, will more than double between now and 2050. If we compare population by continent now and in 2050, we see that Africa will more than double in population (from 1 billion to 2.2 billion) while Asia and the Americas will grow by 25 percent and Europe will hardly grow at all! Looking at the numbers at the country level gives an even starker picture. To take just one example, Nigeria, which has the biggest population in Africa, will grow from 163 million to 392 million—an increase of 140 percent. This will likely make the lives of people in that very poor country even more difficult. Melinda and I believe, though, that if the right steps are taken—not just helping women plan their families but also investing in reducing child mortality and increasing nutrition—populations in countries like Nigeria will grow significantly less than projected. Almost all the foundation’s global programs focus on goals that will help with this. Globally, more than 200 million women say they don’t want to have a child within the next two years but aren’t using contraceptives. If families that wanted to wait a longer period between births or have fewer children had access to the right tools, two things would happen. First, those families would have an easier time facing the challenges of poverty. Second, as national population growth rates came down gradually, governments would be able to better meet the needs of all their people. A significant number of women indicate that they would use modern family planning tools if they were available. Unfortunately, the funding to buy these tools, to make them cheaper, and to provide high-quality information to poor families has been lacking. The tools that are likely to have the highest adoption rates in sub-Saharan Africa are implants or injectables, not the oral contraceptives that are popular in the United States. Indonesia has made implants broadly available, and more than 1.7 million women are using implants today. The foundation has helped fund quality assurance for a lower-cost implant, Sinoplant II, which is registered today in more than 17 countries and costs 60 percent less than the alternatives. We also think that injections can be made cheaper and longer lasting and put into a format that women can administer themselves. There are a large number of steps required to get new tools not only approved and manufactured but also understood so that women can make informed choices about contraception. Our goal is that every woman should have the ability to choose when she wants to have children. The result will be healthier mothers and children and more prosperous nations.

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