Incentives & Altruism…

For months I’ve been thinking about something. A concept. I’ve been walking around in a haze thinking about one thing. I find myself scribbling about it everywhere I go. Altruism. The many aspects of altruistic behaviour lead me to apply it to everything. From economics to charity. From friends and family to relationships. From Mother Teresa to Adam and Eve. And from neglected tropical diseases to vaccines.

Vaccines are easy for the public and donors to understand – vaccinate a child, save a life. The ink is firmly dry on the recent deal ensuring vaccines for some of the world’s poorest children. Donors pledged $4.3 billion to GAVI to help immunize 250 million children by 2015. “One child vaccinated every two seconds for five years” was the very media-friendly soundbite issued by the British Prime Minister David Cameron. Along with the conclusion of the Pacific Health Summit in Seattle last month and a unique malaria vaccine in the final stages of testing, it seems the global health theme this year is vaccines – or, more specifically, antipoverty vaccines. Vaccines are cheap, require no clinical diagnosis, and little training, equipment or expertise to implement.

Funding vaccine research is far from altruistic. It is subject to the same market principles that plague the development world – incentives need to be created for pharmaceutical companies to invest in research and development (R&D). Since the end of the last century it has been clear that an alternative model for R&D of afflictions of the poorest was needed. Significant advancements have been made in increasing distribution and development of vaccines against childhood killer diseases – including pneumococcal disease, rotavirus, and Haemophilus influenzae Type B. The recent pneomococcal vaccine launched last December is one of the few success stories in public health in recent years. The stretch of land in sub-Saharan Africa; from Senegal to Ethiopia, encompassing almost 500 million people within 13 countries – the continually expanding “meningitis belt” – has suffered from devastating epidemics of meningococcal meningitis for over a century. Last year, thanks to a collaboration between PATH, WHO, suppliers from the Netherlands, conjugation technology from the USA, and manufacturers from India a unique solution to a specific problem was created; an affordable long-lasting vaccine that sub-Saharan Africa could afford. To date, the Meningitis Vaccine Project has vaccinated 19.5 million people and it is hoped that 300 million people across 25 countries in sub-Saharan Africa will receive it by 2015.

Vaccines are big business and in reality the research and development landscape for getting life-saving vaccines to those who need it are far from easy. Vaccine pricing and access remains a high priority among donors and recipients alike trying to navigate the quagmire of corporate interest, altruism, and economics. Not everyone is won over by incentive-based approaches to R&D. Medecin Sans Frontières and Oxfam have been vocal about value for money and the drawbacks of the Advance Market Commitments (AMC) that ensure a future market for vaccines that pharmaceutical companies have no interest in developing for the bottom billion. There is little incentive for pharmaceutical companies to conduct R&D for diseases that affect populations with limited purchasing power.

A vaccine usually begins its life by being developed and tailored to wealthy industrialised countries. The high prices recouping development costs and ensuring the highest rates of market return. Vaccines typically reach the developing world a decade after they become available elsewhere. One advantage of the AMC is it bypasses the wait, allowing rapid rollout in developing countries. To date, most work on AMCs has been applied to vaccine development. This recent upswing in antipoverty vaccine development is a good start but has overlooked many neglected diseases. Some NTDs continue to be unaddressed by vaccines altogether, while many vaccines are not well-adapted for people in developing countries. What remains is the lack of a market pull incentive to turn basic R&D into useable products. The AMC represents a pull mechanism that isn’t quite strong enough to forge the development of new and sophisticated tools for tackling diseases of poverty, and yet is the best approach thus far.

More financial models for NTDs are needed. Some that cover more than one product type, for initiatives in various stages of development, and already existing health interventions. The launch of the Orphan Drug Act in the US spurred on a tenfold increase in the market of products for diseases that affect less than 200 000 Americans. During the early 1990s pharmaceutical companies responded to the UK’s Ministry of Health’s call for a new vaccine for meningitis C. The precedent is there.

We would all love for “Big Pharma” to be a little bit more altruistic. Investment, drugs and technologies into NTDs would be easier to develop than, say, dietary drugs where the market runs into billions of dollars. Altruism doesn’t seem to exist in a void. Until it does, we will have to persist with the carrot and stick model.

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What had I twaught…


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