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When Words Fail

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Vaccination Week in the Americas Goes Global

On the Brink of a Watershed Moment for HIV Vaccine R&D

Reflections of a Lifetime Dedicated to Public Health Advocacy - In Memory of Beth Waters

When Words Fail

By: Bill Foege

Someday this may even be known to historians as the vaccine age. It started 215 years ago when Edward Jenner gave the first vaccination to James Phipps, using material from the cowpox lesion on the hand of Sarah Nelms. Jenner had no knowledge of viruses, vaccines or vaccinology but he was attempting to duplicate what he had observed in nature, namely that milkmaids were protected from smallpox, evidently because they had experienced cowpox lesions on their hands from milking cows.

This was also the beginning of modern public health because now there was a tool that could be used to prevent disease. While the first vaccine goes back two centuries, the field has exploded in my lifetime. My mother bought a baby book when I was born more than 75 years ago and it mentions only two vaccines. But now we use 18 routinely and another dozen for certain age groups or certain geographic areas of the world.

The end is not in sight. The vaccines increase in number, become better and safer, and will become easier to administer. It is a stunning use of science in the service of people everywhere. Not only is the approach less expensive than so many things we do in medicine, but it lends itself to equity because it is possible to reach such a high proportion of the world’s population. We can expect more diseases to be eliminated from the world and on the horizon we can see better vaccines for tuberculosis, effective vaccines for malaria and the prospects even improve for a vaccine against HIV.

Infectious diseases have been the basis for most vaccine development but even while concentrating on infectious diseases, it has been possible to develop two anti-cancer vaccines, Hepatitis B vaccine to prevent liver cancer and Human Papilloma Virus vaccine to protect against carcinoma of the cervix. It is predictable that we will, in the future, give a variety of vaccines to protect against other cancers but perhaps also against heart disease. Some think there will be vaccines to reduce the cravings for tobacco, alcohol or other drugs. Others dream of vaccines to delay or prevent dementia. No possibility should be ruled out at this time.

The burden for global health workers is to provide better delivery programs. It has often been said that if we can’t develop good immunization programs it is unlikely that we can deliver other health services. In a similar vein, if we can’t deliver six vaccines well, it is unlikely that we can do better with 12. But now we must seriously plan for the day that we are routinely giving two dozen vaccines and then even more. It is a serious challenge to impress on national health agencies that this is the most cost-beneficial program possible. We can’t take it lightly.

As if the science and delivery problems aren’t enough, we now find, in Europe and the U.S., an increasing movement that questions the safety of vaccines. The professionals have a hard time keeping up on the various vaccines, schedules and best use. When even presidential candidates raise untrue accusations on the safety of the HPV vaccine, it is no wonder that average people who lack a staff to vet truth get confused. Our jobs increase in complexity as we struggle to provide this truth to the public in ways that are transparent and easily understood. But the possibilities for better health as the result of effective vaccine programs is so enormous that we must take this task seriously.

And we must respond faster to people such as Andrew Wakefield who provide false information. It required enormous resources to counter his deceptive and false accusations. This was money not available for essential research into the actual causes of autism. As parents we have so much to worry about that it is unconscionable that we need to worry about things that are not true. Those parents who reject vaccines are actually trying to protect their children, they aren’t fighting science, but we need to know how to make science available to them. When presidential candidates contend that global warming is fraudulent and an attempt by scientists to get more resources, the price of scientific illiteracy becomes obvious. We need to do better.

There are many stories that I struggle to get right…and never do. I mention two here. The first is the inability to satisfy for others or myself, the joy of illness not encountered.

This year, the Measles Initiative celebrated 10 years of work and 1 billion (yes billion) children immunized against measles. I reminisced with the group what measles meant in Africa when I began working in rural Nigeria 46 years ago. A measles death awaited 7 percent to 8 percent of all children. It doesn’t mean that life is now great for children in Nigeria, but it does mean that parents don’t lose their children as often.

I have made use of the health care delivery system repeatedly, with a ruptured vertebral disc removed, a hip replaced, successful cancer surgery, just to mention the half of it. Each time I am fully aware of the debt I owe to people and a system that works. I am grateful and it is like being rebooted. I have renewed energy to resume.

But I can’t elicit the same feeling when I reflect on the fact that I have never had smallpox or cholera, diphtheria, pertussis, yellow fever or even malaria. Yet the impact is the same, freedom from illness that allows me to live and love and be productive. If I can’t even get myself to a level of gratitude for those who have gone before and made this possible, how can I elicit such an emotion in others? It would be futile to hope that a secondary student in Nigeria should reflect for a moment on what they owe to an army of health workers.

So words fail to convey the depth of what global health workers have done and continue to do. But rest assured that the world is different and better because of the way you spend your days. Be secure in the knowledge that your effort was worth it. Earlier this year, a young man won the Medal of Honor for heroic efforts in saving others in Afghanistan. He was embarrassed for being recognized for what he described as the “Worst day of my life.” You would also be embarrassed if your efforts put you on a pedestal of public recognition, so perhaps the secure knowledge of what you have meant to the world is sufficient.

The other story I can’t get right because of an inadequate vocabulary, is the importance of every person in the entire chain which leads to better health. A billion measles immunizations isn’t simply a number…although it is an impressive number. Behind that number is an array of occupations and people that simply can’t be visualized.

People of all kinds. We tend to write about the researchers and I specifically mentioned Maurice Hilleman and his role in developing measles vaccine while working for the Merck Drug Company. But he was dependant on a thousand people in a single corporation doing everything from ordering glassware to processing travel vouchers to cleaning the laboratory each night. Did they have any inkling that they were saving the lives of children in Africa? Not unless someone made it clear to them.

And Merck in turn was dependant on hundreds of other companies to provide everything from cardboard boxes for shipping the vaccine to companies making vials and stoppers, needles and syringes and producing paper for requisition forms.

Where does it stop? It took airplanes and vehicles and all of the companies they bought parts from. It took an education system so vast that it spreads throughout the world to get the vaccinators, health educators, politicians and school systems involved in some way.

Obviously an enterprise of this magnitude results in many errors, problems and defects. Things do go wrong. But for these one billion immunizations everything worked. For each of those 1 billion children, the process reached perfection. While I am moved and emotional about the impact of this vaccine effort, I am at a loss for words in trying to describe the value of every person in that chain of perfection.

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Bill Foege, MD, MPH is senior fellow at the Bill & Melinda Gates Foundation.