The Optimist

Shot in the Dark

The biggest hurdle to eradicating disease isn't access to vaccines -- it's getting people to take them.

In 2009, veterinarians at the U.N. Food and Agriculture Organization made a remarkable announcement: Rinderpest, a livestock-borne disease, would soon be eradicated. OK, so maybe it wasn't front-page news, but rinderpest -- which causes animals to develop fever, followed by diarrhea and (frequently) death -- has over thousands of years been a recurring plague on human civilization. It has destroyed the food supplies of entire countries such as Ethiopia, which lost a third of its population to a rinderpest-related famine in the late 19th century. The FAO's eradication effort, launched in 1992, marks only the second time a disease has been deliberately wiped off the face of the Eearth; the first, better-known case was smallpox, which killed between 300 million and 500 million people over the course of the 20th century before its eradication in 1980.

On June 13, the global community tried for a repeat performance with a pledge drive, held by the Global Alliance for Vaccines and Immunization (GAVI). Thanks to support from aid agencies from Britain to Russia, as well as the Gates Foundation, GAVI raised $4.3 billion to immunize 250 million kids worldwide between now and 2015, protecting against diseases from tetanus to tuberculosis, whooping cough to diphtheria. It's a daunting project, but one that is less implausible than it once was: The range of diseases that can be prevented is growing ever longer, and now includes HPV, rubella, typhoid, and Japanese encephalitis. Vaccines for malaria and dengue fever may not be far behind, and there's even some hope for HIV. GAVI itself boasts a strong track record: Over the organization's first decade, more than 5 million child deaths were prevented though more rapid introduction and increased coverage of vaccines in low-income countries. But, going forward, the alliance is going to have to think more about getting parents to vaccinate their kids -- the demand side of health-- especially if it wants to repeat the huge victory of wiping out a disease.

Although few in the public-health NGO community would like to admit it, eradicating diseases is at least as dependent on luck as it is on planning and persistence. Universal vaccination -- the only nearly surefire means of eradication -- is an impossibility in most countries. Even the best-resourced campaigns have to deal with the trouble of reaching remote villages over rutted roads to deliver vaccines that sometimes need to be kept refrigerated, often are difficult to administer, and can take multiple shots to take effect. Add to that the challenge of reaching people who often have no official registration or address, and you can see the problem.

Health professionals instead rely on the strategy of trying to vaccinate enough people, especially in the immediate period of an outbreak, so that the disease eventually retreats toward extinction -- always a dicey prospect. Donald Henderson at Johns Hopkins University wrote of smallpox eradication that it "was achieved by only the narrowest of margins" while progress "wavered between success and disaster, often only to be decided by quixotic circumstance or extraordinary performances by field staff."

Today, the world appears to be walking the same knife-edge with polio. The Global Polio Eradication Initiative was launched in 1988 when there were about a third of a million cases worldwide. Indigenous polio was eradicated in the Americas in 1991 and China in 1996. By 1997, the worldwide total of cases was down to 7,000; by 2009, there were only 1,600. But new cases keep popping up: That same year saw outbreaks in Uganda, Mali, Togo, Ghana, Ivory Coast, and Kenya.

The problem wasn't vaccine supply; the world has spent $8.2 billion on eradication programs, which bought both vaccines and the human infrastructure required to deliver them. Rather, it was a demand issue, one that hinged in particular on the attitude of governments and parents.

Take the example of the polio vaccination campaign in northern Nigeria in 2003, which responded to a particularly virulent outbreak that was threatening to spread. The governor of Kano state refused to support the vaccination campaign because of rumors that the vaccines were laced with drugs that would sterilize recipients -- which he claimed was part of a U.S. conspiracy to depopulate the developing world.

To be fair to Kano's former governor, only 23 percent of children across the whole of Nigeria were fully immunized in 2008, suggesting that general lack of information, fear of side effects, and the hassle of getting kids vaccinated probably played the larger part in low takeup of polio vaccine on the demand side (not to mention weaknesses in the vaccine delivery and administration system). But that only emphasizes the fact that without at least some support from both local officials and parents, there is no way to complete a vaccination program.

Issues with government prioritization help to account for the fact that about 55 percent of surveyed kids are fully vaccinated in low-income countries, according to my colleague Amanda Glassman at the Center for Global Development -- but only 42 percent in lower-middle-income countries are. And in fact, demand-side problems affect the whole world, not just the developing parts of it that are typically the focus of immunization efforts. More and more parents in Europe and the United States have refused to vaccinate their kids over the fear (despite overwhelming evidence to the contrary) that the vaccines lead to autism.

What about the less conspiracy-minded corners of the world? MIT economists Abhijit Banerjee and Esther Duflo, authors of this year's development blockbuster Poor Economics, studied vaccination rates in Udaipur, India and found that only 16 percent of children below age 2 there were fully immunized against the standard preventable diseases. That was due in part to the limited provision of immunization clinics, but it was also because of low demand for the free immunizations that were available: Even when a local NGO helped ensure regular and well-publicized visits by traveling immunization camps in parts of Udaipur, full immunization only increased from 6 percent in control villages to 18 percent in villages that saw regular camps. World Bank research in India suggests one reason why -- many parents do not fully appreciate the health benefits of vaccination and so are unwilling to go to the effort of attending an immunization camp.

One effective response if the kids won't come to the vaccines is to take the vaccines to the kids. If families are visited at home by a trusted health worker, the World Bank research suggests parents are very happy to see their kids stuck full of needles. But the trouble with such an approach is that house visits are a very expensive way to guarantee coverage. So Banerjee and Duflo tried adding an incentive to get parents to bring their kids to camps, instead -- a 2-pound bag of lentils for each immunization and a set of plates if parents ensured their kids got the full program. That more than doubled the full immunization rate to 39 percent in villages where the incentives were offered and even increased immunization rates threefold in neighboring villages. And because the incentives increased the efficiency of the camps (i.e., how many kids were vaccinated each day), they actually reduced the overall cost of providing immunization coverage, from $56 per child without incentives to $28 per child.

The long-term answer to raising vaccination levels worldwide is to spread knowledge of their safety and efficacy. But as both the polio vaccine scare in Nigeria and the recent gross irresponsibility of a doctor and his Hollywood acolyte over vaccines in the West demonstrate, that process can be complex. In the meantime, providing direct incentives to people to get their kids vaccinated are likely to have a more immediate impact on changing behavior -- and that will reduce both the immense human costs of infectious disease and the considerable financial costs of preventing them.

Christopher Furlong/Getty Images

The Optimist

Green Shoots in the Killing Fields

Citizens of the Democratic Republic of the Congo believe there's hope for their war-torn country even if no one else does -- and their optimism is starting to get results.

After more than 100 years of abuse, the Democratic Republic of the Congo is surely the most dysfunctional country on the planet. It started the 20th century under Belgium's King Leopold II, who oversaw the deaths of millions through exploitation and disease in what was then his personal fiefdom of the Congo Free State, a tyranny made notorious by Joseph Conrad's Heart of Darkness. Independence in 1960 was accompanied by a vicious civil war and, soon after, the CIA-backed rule of Mobutu Sese Seko, one of the most kleptocratic leaders in world history.

Mobutu's presidency ended in 1997 amid renewed civil conflict, which in the decade that followed killed somewhere between 1.8 million to 5.4 million people (the number is subject to dispute). The social disintegration that accompanied the war has bordered on the medieval. In South Kivu province last year, as many as 40 women were raped every day, and one in 10 of them contracted HIV as a result. Last week, the country was declared the second-worst place in the world to be a woman -- one place behind Afghanistan -- by TrustLaw, an NGO that tracks governance and women's legal rights.

Given that history, it is perhaps unsurprising that, according to data from the late economist Angus Maddison, the country was one of only three in the world to see its economy shrink over the past 40 years (the other two were North Korea and Iraq). National output was $16.7 billion in 1970; it was $16.6 billion in 2008. This occurred while the population climbed from 22 million to 67 million people, leaving income per capita only a third of its level in 1970. Between 1990 and 2007 alone, World Bank data suggests that the proportion of the population living on less than $1 a day -- absolute poverty -- increased from 60 to 71 percent. Today the average income is around 68 cents a day, which means most people are living for a week on the price of one McDonald's Happy Meal. In fact, Maddison's estimates suggest that at no point since 1820 has anywhere in the world been as poor as the Congo has been in the past few years.

So it may be near impossible to believe that the heart of darkness isn't quite as nightmarish as it once was. But over the same 1990 to 2007 period in which poverty was spreading, according to the World Bank, infant mortality rates dropped from 15 percent to 9 percent. That's still horribly high, but it means that a child in present-day Congo has a better chance of surviving than a child in South Korea or Mexico in 1960. Maniema, the province of the country that performed worst in the survey, has an infant mortality rate of 13 percent -- below the overall country average in 1990 and below the levels in Peru and Morocco in 1960. The proportion of underweight children has declined. Maternal mortality has also fallen. Even HIV prevalence has dropped, from 4.2 to 3.4 percent of the population.

In no small part, these improvements are connected to the rollout of basic health services. Recent surveys suggest nearly two-thirds of children in the country are vaccinated against diphtheria, whooping cough, and tetanus, and more than half of all households have an insecticide-treated bed net. More than four out of 10 kids who show symptoms of pneumonia get antibiotics, and nearly the same proportion with symptoms of malaria get antimalarials. Forty years ago, when the average income in the Congo was three times what it is today, those treatment rates were close to zero. Prenatal care coverage increased from 56 to 85 percent of the population between 1990 and 2007, and antiretroviral access rates are climbing as well. This spread of lifesaving technologies and support helps to explain why infant mortality is less than it was in the United States in 1900, even though the average American at the time was 16 times richer (adjusted for inflation) than the average 21st-century Congolese.

And it isn't just health. Education rates are climbing by leaps and bounds. Thirteen million Congolese students were enrolled in school in 2007, and the percentage of primary-age kids in school went from 64 to 84 percent between 2006 and 2008 alone. There is now a considerably higher percentage of children in school in the Congo than there was two decades ago -- or, for that matter, in Kuwait and Honduras as recently as 1980.

Given the state of the economy, these achievements have been managed on a pittance. In 2009, according to the World Bank, the Congo's government budget accounted for about 20 percent of GDP -- about $50 per year per citizen. Health and education together accounted for around $9 per year per person -- less than 0.3 percent of what the U.S. government spends per citizen on health care alone. That meager expenditure, augmented by aid and the limited private resources available to individual citizens, was enough to provide a level of health and schooling considerably better than would be expected by far richer countries only a few years ago.

Part of that success story is explained by the advent of new technologies. For example, the Congo is about to benefit from a new vaccine against pneumonia developed with the support of the Global Alliance for Vaccines and Immunization. But it's also a human success story, one that involves health workers turning up to vaccinate kids and provide health services and teachers showing up to class, even amid some of the worst social conditions on Earth -- people like Denis Mukwege, a gynecologist who founded a hospital in the city of Bukavu to provide care for victims of the Congo's epidemic of sexual violence. (Mukwege, ironically, has just been awarded Belgium's King Baudouin International Development Prize for his work -- named after a direct descendent of Leopold II.) Parents across the country, meanwhile, are prioritizing education for their sons and daughters over the help they could provide in the fields or household, and turning up to get their kids vaccinated.

In short, the signs of hope in the Congo are the result of the country's citizens' own belief that things should be better than they are -- and that they can be. It's a remarkable contrast to the cynicism that has defined the country's colonial overlords, native kleptocrats, and odious warlords for more than a century. And thankfully, the people of the Congo seem to be right. It is all a sign that development can occur even in the absence of well-functioning institutions of governance -- and even during a civil war. That, in turn, is a refutation of the idea that we should wait to improve lives, or focus on sustainable development, until bureaucracies function with clockwork efficiency and the rule of law is universally applied. Poor governance is no reason to deny support to some of the people who need it most.