My dream at the end of every day is to close my eyes, knowing that the access to prevention, care and treatment has improved for Rwandan children and people of the world.
A hero of mine wrote from prison that “human progress never rolls in on
wheels of inevitability; without hard work, time itself becomes an ally of
social stagnation.” Dr. Martin Luther
King Jr.’s words have long resonated with Africa’s struggle against global cynicism
in the fight against AIDS. At the turn of the millennium, while I practiced as
a pediatrician in Rwanda, international experts brandishing computer-generated prescriptions
of cost-effectiveness told us then that the time just wasn’t right to provide
access to the effective treatment widely available in their own countries. In
short, African lives were worth less than American or European lives. Costs
were just too high, they said (never mind that activists soon drove
AIDS drug prices down
from $12,000 to $100 per year). African governments and patients simply weren’t
prepared, they cautioned (never mind that studies show Africans
have far higher adherence to treatment than North American counterparts).
Dr. King’s words came to mind again last week,
when I read with interest a recent commentary in The Guardian on pharmaceutical company donations in
Africa. As an example of
the pitfalls of corporate philanthropy in global health, author Adam Green cited
Rwanda’s partnership with Merck to provide universal access to the human papillomavirus
(HPV) vaccine for the prevention of cervical cancer. He echoed claims made two
years ago by some experts that Rwanda jumped the gun, allowing itself to be used as a pawn by
a predatory multinational corporation.
Yet such arguments keep recurring (for HIV, drug-resistant tuberculosis, cancer, cholera, and so on) because of a larger divide in global
development. Many who advance or tacitly endorse the claims echoed in Green’s piece
often do so because they believe ideological purity (that is, the view that drug
companies often pursue only self-interest) is a moral imperative, and that
cost-effectiveness (that is, poor people should get cheap things) should always
trump other considerations.
But do we truly live in such a zero-sum
world that a win-win outcome from a public-private partnership for health is
unimaginable? Certainly, competition is better for promoting access to
medicines than voluntary donation programs. Yet there are already two companies
making the HPV vaccine, and generic versions are not so far off. Furthermore, the historical gap between
new vaccine introduction in rich and poor countries is two
decades; by working with
Merck, Rwanda reduced it to four years and showed the world one possible
strategy for reaching universal coverage. Just this past week, GAVI made
international news by announcing even lower prices for the HPV vaccine (down to $4.50 per dose) through
agreements with two manufacturers, and approved a grant to continue Rwanda’s national program after Merck support stops in 2014.
So much can be achieved in global health with
shared commitments to teamwork and humility, a willingness to grapple with
complexity, and a big dose of imagination. Indeed, for the very health issues that
Green argued should rank higher than the HPV vaccine, Rwanda (and many other nations)
are already engaged in novel collaborations to address. On top of the HPV
vaccine rollout, we are working with groups around the world to build
synergistic screening and treatment programs for cervical and many other
cancers. In tackling maternal and child mortality, we’re strengthening health
and sanitation systems in addition to teaming up with development partners on a mobile-based
notification system for
community health workers. With the support of GAVI, we’ve rolled out three new childhood vaccines against pneumonia, diarrhea, and rubella
nationwide since 2009. With two-dozen American schools, we are training
hundreds of nurses and specialist physicians.
And it seems to be working: while
spending less than $60 per capita on health, Rwanda is now on track for the Millennium
Development Goals.
Indeed, to those interested in working here, we like to say, “Don’t come for
charity. Come for partnership.”
Adam Green’s piece voiced concerns about programs
like those described above serving as “market priming to create the conditions
for adoption.” From Rwanda’s view, the jury is in: with more women dying of cervical cancer than in childbirth worldwide, the market is quite primed
and demand readily apparent. Supply of the HPV vaccine and many other tools of
modern medicine, on the other hand, remains in doubt for those who need them
most. But with no global solidarity fund for cancer today, how else should we
get started but to forge smart new partnerships? One lesson from AIDS is that
if the world stalls, you just need to act and show that it can be done.
As Dr. King said, in the face of
challenges like growing global health inequalities, “We must use time
creatively, in the knowledge that the time is always ripe to do right.” Let’s
use our time and talents—as health workers, researchers, and journalists—to
work together towards a future in which where
a patient lives doesn’t determine if
they live.
Agnes
Binagwaho is Minister of Health of Rwanda, Senior Lecturer at Harvard Medical
School, and Clinical Professor of Pediatrics at the Geisel School of Medicine
at Dartmouth.
On December 2, a Correspondence letter that I co-authored was published in The Lancet regarding debates about using and paying for the Human Papillomavirus vaccine in low-income countries: “HPV Vaccine in Rwanda: Different Disease, Same Double Standard.” The text of the letter is copied below, and you can click here to read it on The Lancet website. This Youtube Video was recorded to complement the Letter in the Lancet.
We respond to a group of public health researchers who wrote a piece in July that was critical of Rwanda's program and made several claims which have been echoed in other corners of the international community. We draw parallel between this resistance and that of many debates about providing antiretroviral therapy in Africa last decade.
We have detailed articles on strategy, delivery, and outcomes of Rwanda’s program underway, and will post on my blog once they are published.
HPV vaccine in Rwanda: different disease, same double standard
Agnes Binagwaho, Claire M Wagner, Cameron T Nutt
In a Correspondence letter (July 23, p 315) [1] regarding Rwanda's human papillomavirus (HPV) vaccine roll-out, Nobila Ouedraogo and colleagues express “serious doubts that [a national HPV immunisation programme] is in the best interest of the people”. Are the 330 000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this programme not regarded as “the people”?
Ouedraogo and colleagues argue that cervical cancer ranks behind other vaccine-preventable diseases in resource-constrained settings. But for the diseases cited (measles and tetanus), Rwanda has 95% and 96·8% vaccination coverage rates, respectively [2]. Second, Ouedraogo and colleagues state that HPV vaccine effectiveness is unknown. Many studies say otherwise [3]. Third, the cost-effectiveness analysis cited does not account for vaccine market dynamics by presenting assumptions as immutable facts. The initial price of the pneumococcal vaccine provides a helpful lesson, and Merck announced a two-thirds reduction in the price of Gardasil for GAVI-eligible countries (to US$5 per dose) [4] more than a month before Ouedraogo and colleagues published their Correspondence letter. Finally, Ouedraogo and colleagues accuse Merck and Rwanda of conflicts of interest regarding connections to the GAVI Alliance. Actually, Merck representatives are non-voting GAVI observers, and GAVI's website clearly shows Rwanda's board membership terminating on Dec 31, 2011 [5]. GAVI will have no role in the HPV vaccine programme before 2014.
Ouedraogo and colleagues' argument reminds us of nihilistic claims against provision of antiretroviral therapy in Africa. Their argument constitutes but the latest backlash against progressive health policies by African countries. When the possibility of prevention exists, writing off women to die of cancer solely because of where they are born is a violation of human rights.
The opinions expressed in this Correspondence are entirely those of the authors and should not be attributed to Harvard Medical School or Dartmouth College. We declare that we have no conflicts of interest.
References
1) Ouedraogo N, Müller O, Jahn A, Gerhardus A. Human papillomavirus vaccination in Africa. Lancet 2011; 377: 315-316. PubMed 2) Ministry of Health of Rwanda. Demographic and health survey 2010: preliminary report. Kigali: National Institute of Statistics of Rwanda, 2011. 3) Schiffman M, Wacholder S. Success of HPV vaccination is now a matter of coverage. Lancet Oncol 201110.1016/S1470-2045(11)70324-2. published online Nov 9. PubMed 4) Merck . Merck offers further commitment to sustainable vaccine access. http://www.merck.com/newsroom/news-release-archive/corporate-responsibility/2011_0605.html. (accessed Aug 9, 2011). 5) GAVI Alliance. Board members. http://www.gavialliance.org/about/governance/gavi-board/members/. (accessed Aug 9, 2011).
