Eradicating the largest driver of Child & Infant Mortality

Photo by Ben Richardson on Unsplash

As living creatures, we really only have two objectives: living and procreating. By virtue of this, increasing the global life expectancy should be our biggest priority from a humanitarian perspective.

In eyeing this graph, the question almost begs itself; why is it that Sub-Saharan Africa has such a bad (~25%) life expectancy in relation to western countries?

Contrary to popular belief, the biggest driver of short life expectancy in Sub-Saharan Africa isn’t violence, income inequality, etc. The biggest driver of short life expectancy in Sub-Saharan Africa takes place before the age of 5: infectious diseases.

1 in every 13 children in Sub-Saharan Africa die before reaching 5 years old. In Nigeria alone, 858,000 children under 5 years old died just last year. Even in spite of our massive progress during the past two decades, Sub-Saharan Africa’s DALY is abysmal and a breach of human rights in of itself.

45% of children die due to infectious diseases, with lower respiratory diseases, neonatal preterm complications and digestive diseases accounting for 15%, 12% and 10% respectively. For the rest of this article, I’ll be focusing on the largest stakeholder.

What’s worse is that these deaths are completely preventable. We’ve nearly eradicated pneumonia in the west through the use of Pneumococcal Conjugate Vaccine 13 (PCV13), breast feeding, etc. Established solutions to all of these problems have existed for decades, so why isn’t Sub-Saharan Africa using them?

Bringing these resources to low-income countries has proven to be a difficult task. A lack of public infrastructure, decentralized populations and low literacy rates has tremendously hindered progress against protecting infants and children.

To solve this, we need to focus on two major areas in the value chain: vaccination coverage and vaccine cost. Before we dive into either of these, however, we first need to understand how PCV13 works in the first place.

All vaccines use slightly different means to arrive at the ubiquitously desired end. PCV13 is what’s called a protein-polysaccharide conjugate vaccine. These vaccines induce antibody-producing plasma cells based off pneumococcus’s (the bacteria that causes pneumonia) serotypes’s antigens.

A serotype is simply referring to the different micro groups of organisms that exist within a macro species umbrella such as pneumococcus. Most individual micro-organisms belonging to a species will have a varying number and formation of antigens, catalyzing the need to categorize based on serotypes in the first place.

Antigens are a protein or polysaccharide (carbohydrate) present in given parts of microorganisms (ex. SARS-CoV-2 spike protein). They’re capable of initiating an immune response by triggering the formation and release of specific antibodies, a protein produced by the immune system to identify and neutralize foreign objects.

PCV13 includes 13 valents— pneumococcus serotypes — antigens. 7 of said serotypes account for up to 88% of pneumonia related deaths globally: 1, 5, 6A, 6B, 14, 19F and 23F. By being vaccinated with PCV13, you essentially teach your body how to identify these pneumococcus bacterium and kill them upon detection.

Cost — the GAVI dilemma

One of the biggest challenges with distributing PCV13 all throughout Sub-Saharan Africa is the full incremental cost of vaccination campaigns. It’s important to note that contrary to popular belief, the actual cost of vaccines themselves isn’t the biggest issue here.

Fortunately, a feat of this magnitude is nothing new.

In 2019, 74% of infants in Africa were vaccinated with a vaccine called DTP3, not far off from the global 85% average. While this figure may seem insignificant, if we could bring PCV13 to the same coverage as DTP3, we could avoid 400,000 child & infant deaths each year.

But, why? Why was DTP3 so seemingly flawlessly distributed while PCV13 trails so far behind? The answer is GAVI, the Vaccine Alliance.

GAVI is an organization built with the vision of preventing all infectious diseases in mind. They partner private vaccine companies such as Pfizer, BioNTech, etc. with public organizations — namely UNICEF. Using their revolutionary Advance Market Commitment financial program, they’re able to radically reduce the price of vaccines for low-income countries.

In 2015, GAVI was able to drop the cost of vaccines to $5.09 per dose, creating one of the best economic opportunities of all time for low-income countries. Using GAVI supported vaccines, countries were able to earn a baffling $48 for every $1 return on investment.

Because of the obvious benefits of this, both from a humanitarian welfare perspective and economic one, governments started using GAVI vaccines. It was an obvious win in every way imaginable, however a problem arose.

Part of GAVI’s requirements to be funded is that the average GNI per capita does not exceed $1500. As Sub-Saharan Africa continued to rapidly growth its various economies, several low-income countries transitioned into what’s called a middle-income country. As a result, countries such as Kenya that still evidently needed access to the program lost their membership — putting a tough position on the government.

See, a 48x ROI is a no-brainer. Without GAVI support, however, costs per DALY averted start to get tricky. The vaccine cold chain is a highly complex one. From R&D to distribution, vaccine programs cost a lot of money to put in place.

Again, this isn’t anything new. We’ve iterated on our cold chain model thousands of times in the last century alone, and so have most countries. Vaccines are still cost-effective in most cold chain models, even in middle-income countries that have lost GAVI support.

But at the same time, there are tons of models that don’t work. There’s also not a huge margin to experiment; the most successful, affordable cold chain models cost hundreds of millions of dollars. As you can imagine, the lower quality ones are monumentally worse — clocking in at the billions.

In a highly comprehensive study exploring the cost effectiveness of maternal pertussis immunization, the most effective cold chain model created costed $3,184 per DALY averted (in contrast to GAVI’s $5.09 per DALY averted). The other model which applied the same cold-chain, just adjusted for the entire population, cost a whopping $1.27M per DALY averted. That’s steep enough to start the whole “cost of a human life” debate!

All jokes aside, this is a serious problem. The $3,184 per DALY averted — while expensive — is still technically very cost efficient. The $1.27M on the other hand…not so much. The slightest hiccup in coordination could bring the country’s economy to it’s knees — catalyzing the cost issue at hand.

Health Facilities

Again, contrary to popular belief, lack of health facilities isn’t the biggest issue. Numerous public and independent studies are all pointing to the same thing: the actual quality of care being the issue. Now, that’s not to say that access isn’t a problem — just 49% more people are dying from low quality health care than access to health care in the first place.

There’s a couple reasons this is a problem. First and foremost, physicians are ineffectively diagnosing and treating pneumonia patients. In one particular study, participants were only able to accurately detect pneumonia 25% of the time. This is due to the general complicated nature of the disease; pneumonia is relatively difficult to diagnose in the first place. A lack of medical resources — both physical such as technology, budget, etc. and educational — prevents physicians from getting the tools and education they need to properly combat these diseases.

There are numerous reasons why this problem exists. The most prominent of these being understaffed hospitals (in some instances there’s just 1 doctor available to care for an entire community), medical transcription errors from unestablished recording systems and no follow-up monitoring on patients.

It’s worth noting that this is also the result of a poorly coordinated cold chain. Only 3% of Nigeria’s nominal GDP is allocated to public health infrastructure, which in contrast to United States’ 19% is pretty bad. The high costs of successful public health systems are an immense deterrent for the government to invest time and resources into further iterating on the cold chain.

The Future

Looking back at DTP3’s coverage, it’s evident that it’s possible to achieve our huge aspirations. The key to DTP3’s wide coverage was it’s low cost. The affordability of the vaccine promoted governments to invest more time into developing their supply chains because the cost-effectiveness was immediately present. In order to eradicate pneumonia, we need to replicate this with PCV13.

GAVI, like they did with DTP3, started an Advance Market Commitment for pneumococcal vaccine support. Since then, they’ve distributed more than 215 million vaccines across 60 low-income countries. Very soon, these populations will all be ≥50% immune to pneumonia.

As we continue to make massive strides in progress, the outlook of eradicating pneumonia is starting to look really good. Expanding GAVI’s requirements to encompass middle-income countries additionally will become critical, as per WHO’s request.

Wrapping up, you can make a substantial difference in the world by donating to GAVI. There is still a long way to go and many costs to be covered. GAVI is run entirely on donations from people like you, and I can assure you that your money will go a very long way (completely unbiased).

I make articles about breakthrough technologies, effective altruism and philosophy. If you’re interested in that sort of thing, feel free to message me or follow me here on Medium. Thanks for reading!

14 y/o working on PCV13 distribution in low-income countries

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